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LIBRARY 

THE UNIVERSITY 
OF CALIFORNIA 

SANTA BARBARA 

PRESENTED BY 

DONALD SEEKS 






Published by Licence of the Board of Trade under the " Trading 

with the Enemy Amendment Act, 1916." 

DEMENTIA PRECOX 

AND 

PARAPHRENIA 

BY 

Professor EMIL KRAEPELIN of Munich 



TRANSLATED BY 

R. MARY BARCLAY, M.A., M.B. 

From the Eighth German Edition of the " Text-Book of Psychiatry,' 
vol. iii., part ii., section on the Endogenous Dementias 

EDITED BY 

GEORGE M. ROBERTSON, M.D., F.R.C.P. (Edin.) 

Lecturer on Mental Diseases in the University of Edinburgh 
and Physician to the Royal Asylum, Momingside 



CHICAGO MEDICAL BOOK GO. 

COR. CONGRBSS & HONORE STS. 

Chicago 



_^ /^ 



EDITOR'S PREFACE. 

Dementia Precox has excited more interest and 
speculation than any other form of insanity in our time, 
with the possible exception of general paralysis of the 
insane. I therefore value highly the usefulness of the work 
that Dr Mary Barclay has done in thus bringing before 
English-speaking physicians a faithful translation of the views 
of Professor Kraepelin, who is the recognised authority on 
this subject. In no country has there been less inclination 
to accept his doctrines without qualification than in this, but 
so important are they, that every physician of the mind, who 
would keep himself abreast of modern clinical research, must 
be familiar with them. The present work therefore supplies 
a want in giving in an accessible form the complete and latest 
account of this subject by Professor Kraepelin. In addition, 
there is no other publication in the English language which 
deals solely with dementia praecox in all its various aspects. 

Professor Kraepelin informs us that he got the starting 
point which led to dementia praecox being regarded by him 
as a distinct disease, in the year 1896. He admits "that 
Clouston also, who spoke of an ' adolescent insanity,' had 
evidently before everything dementia praecox in view, though 
he did not yet separate it from manic-depressive cases, 
which likewise often begin about this time." The identity of 
Clouston's "secondary dementia of adolescence" with the 
chief forms of dementia praecox is quite apparent to anyone 
reading the remarkable address on dementia which he 
delivered in 1888 when President of the Medico-Ps^^chological 
Association. While, however. Sir Thomas Clouston regarded 
some of his cases of adolescent insanity as being of an un- 
favourable type which often ended in secondary dementia. 
Professor Kraepelin would regard these very cases, from their 
initial symptoms onward, as being examples of a distinct 
form of disease, namely dementia praecox. This situation 
therefore recalls in an interesting manner the circumstances 
connected with the discovery of general paralysis of the 
insane. Esquirol and his pupils had for seventeen years been 
observing cases of "insanity complicated with paralysis," 
when Bayle, in 1822, boldly asserted that the symptoms of 
this clinical condition were those of a separate and definite 
disease. This hypothesis has proved true ; is it too soon yet 
to say the same of the former ? 



ii EDITOR'S PREFACE 

Professor Kraepelin's task in depicting the characteristic 
features of dementia pr.tcox has not been an easy one, and 
even now he has not reached finality in his opinions. He is 
not satisfied with his delimitation of its boundaries, nor with 
all the sub-divisions which he has created, though he believes 
that his main thesis has been substantiated. Neither terminal 
dementia nor precocity is, however, an essential element of 
the clinical picture, though his reluctance to discard the 
former is very evident, and this masterly summary has been 
as a matter of fact prepared solely from observation of cases 
which actually became demented. 

Now that general paralysis of the insane, after a century 
of observation and research, has yielded up most of its 
secrets, by far the most important practical problem facing 
the psychiatrist and the community, in the domain of mental 
hygiene, is that of dementia praecox. The patients suffering 
from this disease form the major part of the inmates of our 
mental hospitals. The heavy financial burden imposed upon 
the public for the treatment of the insane, resolves itself 
therefore very largely into the outlays needed for the lifelong 
care of the almost hopeless victims of this disorder. More- 
over, as the disease does not directly cause death, and as 
such patients lead protected lives and live long, they tend 
to accumulate. They thus form the chief reason for the 
periodical necessity of enlarging our mental hospitals, and of 
erecting new ones. Could a study of the causes and treatment 
of this disorder result in its prevention or diminution, its cure 
or alleviation, a practical benefit to society of the most direct 
and valuable kind would be conferred. Such an enquiry 
should have the support of the Ministry of Health as this 
disease costs the State more than any other. How to avert this 
dementia continues to be the cardinal problem of psychiatry. 

It is hoped that the publication of this translation will 
stimulate the interest of English-speaking physicians in 
these peculiar states of mental enfeeblement, promote further 
clinical observation and research, and lead to greater accuracy 
of diagnosis and prognosis, with a better understanding of 
the nature of the disease. 

GEORGE M. ROBERTSON. 

U.NIVERSITY OF EDINBURGH, 
July 1919. 



TRANSLATOR'S PREFACE. 

As the aim of this translation is to bring the views of 
Professor Kraepelin, of Munich, on dementia praecox before 
the English-speaking members of the medical profession who 
may not be intimately acquainted with German, I have made 
it as literal as seemed consistent with readable English, 
Professor Kraepelin's Psychiatry is the leading German text- 
book on disorders of the mind, and I therefore willingly 
acceded to the wish of Dr George Robertson to make a 
complete translation of the section on dementia praecox. 
This special disease still requires much elucidation, and in 
its study medical practitioners, educationalists, and crimin- 
ologists may well work together. It is especially on the 
educational side that Professor Kraepelin's observations or 
investigations appear to be deficient. It should not be 
difficult in this country to collect the required facts relating 
to individual cases, and to a certain extent this is being 
done already. When these facts are classified, much benefit 
should accrue to education, medical advancement, and the 
public welfare. 

To Dr George Robertson I have to express my thanks 
for many useful suggestions, and to Dr Walker for the 
unwearying care with which he has revised the proofs. 

R. MARY BARCLAY. 
Edinburgh, July 1919. 



CONTENTS. 



Prbface ....... 

Introduction— THE ENDOGENOUS DEMENTIAS 

I. DEMENTIA PRECOX 

II. PSYCHIC SYMPTOMS 

Perception ..... 

Attention ..... 

Hallucinations (thoughts heard, thought influence) 

Orientation ..... 

Consciousness ..... 

Memory . . " . 

Retention (pseudo-memories) . 

Train of thought (loss of mental activity) 

Association 

Stereotypy 

Paralogia, evasion 

Constraint 

Mental efficiency 

Judgment 

Delusions 

Emotional dulness, ataxia of the feelings 

Weakening of volitional impulse 

Automatic obedience (catalepsy, echolalia, echopraxis) 

Impulsive actions .... 

Catatonic excitement .... 

Stereotyped attitudes and movements 

Mannerisms ..... 

Parabulia ..... 

Negativism (autism, stupor) . 

Personality ..... 

Practical efficiency .... 

Movements of expression 

Incoherence ..... 

Stereotypy (verbigeration) 

Negativism (mutism, evasion) 

Derailments in word-finding . 

Paraphasia ..... 

Neologisms ..... 

Akataphasia ..... 

Syntax ..... 

Derailments in train of thought 

III. GENERAL PSYCHIC CLINICAL PICTURE 
Blunting of emotions .... 
Intrapsychic ataxia .... 



CONTENTS 



Chap. 
IV. 



Pace 



BODILY SYMPTOMS 
Headaches 
Pupillar)' disorders 
Tendon reflexes 
Muscular movements 
Seizures 
Grimacing 
Aphasia 

Vasomotor disorders 
Blood -pressure 
Respiration 
Secretion of saliva 
Temperature . 
« Menses 

Blood-picture . 

Metabolism 

Changes in the thyroid 

Sleep . 

Nourishment . 

Weight 

V. CLINICAL FORMS 

Dementia praecox simplex 

Silly dementia prsecox, hebephi 

Simple depressive dementia praecox, stupor 

Delusional depressive dementia praecox 

Circular dementia pnecox 

Agitated dementia prjEcox 

Periodic dementia prcecox 

Catatonia, excitement, stupor (melancholia attonita) 

Paranoid dementia praecox, gravis 

Paranoid dementia pnrcox, mitis 

Confusional speech dementia proecox, schizophasia 

VI. COURSE, REMISSIONS 

VII. ISSUE . 

Recovery, recovery with defect 
Simple weakmindedness 
Hallucinatory weakmindedness 
Paranoid weakmindedness 
Drivelling dementia 
T)ull dementia 
Silly dementia 
Manneristic dementia 
Negativistic dementia 
Prognostic indications 
Death, mortality 

VIII. MORBID ANATOMY 
Cell morbidity 
Changes in glia 



CONTENTS 



Vll 



Chap. 



IX. 



XL 



XII. 



XIII. 



Atrophy of medullary fibres .... 
Relations of the changes in the cortex to the clinical picture 

FREQUENCY, CAUSES 
Time of life 
Engrafted hebephrenia 
Idiocy 

Dementia prsecocissima 
Late catatonias 
Dementia tardiva 
Sex 

General conditions of life 
Hereditary predisposition 
Injury to the germ, alcoholism, syphilis 
Personal idiosyncrasy . 
External causes — over-exertion, infection, syphilis, head 

injuries, alcohol, imprisonment, reproduction 
Sexual life . . . , , 

Auto-intoxication .... 

Freudian complexes .... 

DELIMITATION . . , . 

Paranoid 'forms .... 

Catatonia . . . . . 

Late catatonias .... 

Periodic forms .... 

Confusion of speech .... 

DIAGNOSIS 

Catatonic symptoms .... 
Psychopathic states .... 
Imbecility and idiocy .... 
Manic-depressive insanity 
Hysteria ..... 

Psychogenic psychoses 

Dissimulation ..... 
Epilepsy ..... 

Paralysis ..... 

Amentia (confusional or delirious insanity) 
Cerebral syphilis .... 

Paranoid diseases .... 

HOW TO COMBAT IT . . . 

Treatment of the cause (castration, immunization, excision o 

the thyroid), prophylaxis . 
Treatment of the morbid phenomena, occupation 
Treatment by leucocytosis 

PARAPHRENIA .... 

Definition and classification . 
Paraphrenia systematica 
Paraphrenia expansiva 
Paraphrenia confabulans 
Paraphrenia phantastica 



LIST OF ILLUSTRATIONS. 



FIG. 
I. 
2. 
3- 
4- 

5- 
6. 

7- 



lO. 

II. 

12. 
13- 

14. 
15- 

16. 

17. 
18. 

19- 

20. 
21. 
22. 

23- 

24. 

25- 

26. 
27. 
28. 
29. 
30- 

31- 
32. 
33. 
34. 
35- 
36. 
37- 



Calculation Tests 

Bodilj Influences 

Group of Schizophrenic Patients 

Waxy Flexibility {a) 

Waxy Flexibility (6) 

Waxy Flexibility {c) 

Hair-pulling Patient 

Embroidered Handkerchief . 

Peculiar Stocking (Catatonia) 

Drawings (Metamorphoses) 

Senseless Drawing . 

Queer Drawing 

Normal Finger Movement . 

Simple Finger Movement in Catatonia (a) 

Simple Finger Movement in Catatonia (6) 

Simple Finger Movement in Catatonia (<r) 

Simple Finger Movement in Catatonia (d) 

Normal Rhythmical Finger Movements 

Rhythmical Finger Movements in Catatonia 

Temperature Chart at the End of Life of a Catatonic Patient 

Body Weight in Catatonic Stupor with Dementia 

Body Weight in Catatonic Excitement 

Body Weight in Alternation of Stupor and Excitement with Dementia 

Fluctuations of Body Weight at the Commencement of Dementia Priecox 

Fluctuations of Body Weight in Periodic Excitement 

Stuporous Patient Lying on the Edge of the Bed 

Finger Contracture in Catatonia 

Stuporous Patient 

Expression of Face in Catatonic Stupor (a) 

Expression of Face in Catatonic Stupor {d) 

Nasal Stopper of a Paranoid Patient 

Ornamented Paranoid Patient 

Hopping Patient 

Patient in Distorted Attitude 

Patient Continually Holding her Head 

Nerve Cells surrounded by Glia Nuclei x 484 

Fibrinous Granules in Glia Cells x 484 



ILLUSTRATIONS 



FIG. 

39- 

40. 
41. 

42. 
43- 



Normal Nerve Cells with Glia Nuclei x 484 

Sclerotic Nerve Cells in Dementia Pra-cox x 484 

Healthy Nerve Cells X 484 ...... 

Highly Morbid Nerve Cells filled with Lipoid Products of 
Disintegration x 484 ...... 

Percentage Distribution of 1054 Cases of Dementia Precox at 
Different Ages ....... 

Idiot with Manneristic Movements ..... 



I'AUS 

217 
217 
218 

218 

226 
228 



SPECIMENS OF WRITING. 



1. Incoherence . 

2. Incoherence with Stereotypy 

3. Stereotypy . 

4. Letter of a Hebephrenic 

5. Writing of a Paranoid Patient 

6. Writing ot the Same Patient Seven Months Later 

7. Paraphrenia Phantastica x § 



57 
58 
64 
100 
174 
'75 
321 



INTRODUCTION. 
THE ENDOGENOUS DEMENTIAS. 

A series of morbid pictures are here brought together 
under the term " ^endogenous deme ntias " merely for the 
purpose of preliminary inqu^rJ^ Their clinical relations are 
not yet clear, but they all display two peculiaritie s, that they 
are in the first place, so far as can be seen, not occas ioned 
from without but arise froni internal causes , and that secondly, 
at least in the great majority of cases, they lead to a more or 
less vvel l-ni arked mental enfeeblement. It appears that this 
form of mental weakness, in spite of great differences in detail, 
exhibits many features in common with other forms of 
dementia, such as are known to us as the result of paralysis, 
senility or epilepsy. For this reason I have hitherto descrTbe3 
under the one name, dementia pra;cox . the morbid pictures 
under consideration. Bleuler also has taken them to^rether 



in his "group of the schizophrenias," without trying to make 
a further division of this group. I consider it an open 
question whether the same morbid process is not after all the 



cause of Jj^p (^u/prgpnf- fnrmt; though differj ii p ^ in the poiiif of 
attack and taking a varymg- cours e. It appears to me 
expedient at the present stage to separate out a number of 
these clinical pictures from the domain of dementia praecox, 
which in any case is very e xtensiv e. Nevertheless it is 
dementia praecox w.hich we must take as the first division of 
the endogenous dementias to be reviewed. 

These clinical pictures referred to differ considerably in 
one direction or another from the current conceptions of 
dementia praecox. It would perhaps have been possible to 
carry this separation still further, and, for instance, allow a 

A 



2 INTRODUCTION 

separate place also to the forms which have a periodic course, 
or which lead to confusion of speech. Meanwhile this has 
not been done, and therefore, to begin with, only those forms 
have been singled out and placed together subsequently^ 
which are distinguished in their whole course by very definite 
manifestations of peculiar disturbances of intellect while 
lacking enfeeblement of volition and especially of feeling, or 
at least such symptoms are only feebly indicated. It seems 
to me that the term " paraphrenia," which is now no longer 
in common use, is in the meantime suitable as the name of 
the morbid forms thus delimited which are here by way of 
experiment brought together. 

' Chapter xiii., p. 283. 



CHAPTER I. 

DEMENTIA PRiECOX. 

De mentia pn ec ox^ consists of a series of states, the 
coinj ioif^ characteristic of whiclT is a peculiar_dgsitru(:!tioti of 
the internal _CDi3iiections~~ot the psyoTic" personalityT " Ihe 
el!ects of this injury pr^iixyrfnnSXe~^n the ' ^etfTolIorf al and 
volitional spheres of m ental life. To begin with, the assertion 
that this is a distinct dT5e^se"has met with repeated and decided 
opposition, which has found its strongest expression in the 
writings of Marandon de Montyel and of Serbsky.- But 
even though in many details there are profound differences 
of opinion, still the conviction seems to be more and more 
gaining ground that dementia praecox on the whole represents 
a well char acterised form of disease, and that we are justified 
in regarding^ the^maJorTfy*'at-v£ast of the clinical pictures 
which are brought together here as the expre ssion of a single 
morbid process, though outwardly they Slt en diver ge veryfar 
from one a nothe r. 

" THe^oBJections have been directed even more against the 
name than against the c linical co ngeftUon. I got the starting 
point of the line of thought wlT^h in iBg6 led to dementia 
praecox being regarded as a distinct disease, on the one hand 
from the overpowering impression of the states of dementia 
quite similar to each other which developed from the most 
varied initial clinical symptoms, on the other hand from the 

' Finzi e Vedrani, Rivista sperim. de freniatria, xxv. 1899 ; Christian, Ann. 
medico-psychol. 1899, i, 43 ; Tromner, Das Jugendirresein (Dementia piKCox), 
1909; Serieux, Gaz. hebdomad. Mars 1901 ; Revue de psychiatrie, Juin 1902; 
Jahrmiirker, Zur Frage der Dementia prcecox. 1902; Meeus, ,de la demence 
precoce chez lez jeunes gens. 1902 ; Masselon, Psychologic des Demences 
precoces ; de la demence precoce. 1904 ; Stransky, Centralblatt fiir Nei venheilkunde 
xxvii. I ; tJber die dementia praecox. 1909 ; Bernstein, AUg. Zeitschr. f. Psychiatrie, 
Ix. 554 : Deny et Roy, la demence precoce. 1903 ; Pighini, Rivista sperimentale 
di freniatria, xxxiv. 3 ; Hochp, Deutsche Klinik von Leyden-Klemperer, vi. 2, 
197; HeclU, American Journal of nervous and mental diseases, 1905, 689; 
Evensen, Dementia praecox. 1904 ; Rizor, Archiv f. Psychiatrie. xliii. 760 ; Wieg- 
Wickenthal, Zur Klinik der Dementia prjecox. 1908 ; Bleuler-Jahrmiirker, 
AUgem. Zeitsclir f. Psychiatrie, Ixv. 429 ; Bleuler, Dementia praecox oder 
Oruppe der Schizophrenien, Aschaffenburgs Handbuch der Psychiatrie, 191 1 
(Literatur) Deny et Lhermitte, Traite international de psychologic pathologique, 
ii. 439, 191 1. 

'^Serbsky, Annales medico-psychologiques 1903, 2. 379; Marandon dc 
Montyel, ebenda 1905, 2, 246 ; Soutzo, ebenda 1907, i. 243. 



4 DEMENTIA PRECOX 

experience connected with the observations of Hecker that 
these peculiar dementias seemed to stand in near relation to 
th e period of youth . As there was no clinical recognition of 
it, the hrst thing to be done for the preliminary marking off 
of the newly circumscribed territory, was to choose a name 
which would express both these points of view. The name 
"dementia praecox," which had already been used by MoreP 
and later by Pick (i 891), seemed to me to answer this purpose 
sufficiently, till a profounder understanding would provide an 
appropriate name. 

It has since been found that the assumptions upon which 
the name chosen rested are at least doubtful. As will have 
to be explained more in detail later, the possibility cannot in 
the present state of our knowledge be disputed, that a 
certain number of cases of dementia praecox attain to 
complete and permanent recovery, and also the relations to 
the period of youth do not appear to be without exception. 
I certainly consider that the facts are not by any means 
sufficiently cleared up yet in either direction. If therefore the 
name which is in dispute, even though it has been already 
fairly generally adopted, is to be replaced by another, it is to 
be hoped that it will not soon share the fate of so many names 
of the kind, and of dementia praecox itself in giving a view of 
the nature of the disease which will turn out to be doubtful 
or wrong. 

From this point of view, as Wolff showed, a name that as 
far as possible said nothing would be preferable, as dysphrenia. 
Ths name proposed by Evensen " amblynoia," " amblythymia," 
further the "demenza primitiva" of the Italians, or the one 
preferred by Rieger, which meanwhile has certainly been 
already used in a narrower sense, " dementia simplex,'* 
might also be taken into consideration. Bernstein speaks of 
a " paratonia progressiva," a name that would suit only a part 
of the observed cases. Other investigators accentuate the 
peculiar disturbance of the inner psychic association in our 
patients and call the disease " dementia dissociativa," 
" dissecans," " sejunctiva " or with Bleuler " schizophrenia." 
It remains to be seen how far one or other of these names 
will be adopted. 

' Morel, Traite des maladies mentales, 566, i860. 



CHAPTER II. 
PSYCHIC SYMPTOMS 

The complexity of the conditions which we observe in 
the domain of dementia prsecox is very great, so that their 
inner connection is at first recognizable only by their 
occurring one after the other in the course of the same 
disease. In any case certain fundamental disturbances, 
even though they cannot for the most part be regarded as 
characteristic, yet return frequently in the same form, but in 
the most diverse combinations, We shall therefore try to 
give a survey of the general behaviour of the psychic and 
physical activities before we describe the individual clinical 
manifestations of the disease.^ 

Perception of external impressions in dementia praecox 
is noTnJsually lessened to any great extent as far as a 
superficial examination goes. The |3atients perceive in 
general w hat ^oes on arou nd them often much better than 
6nfe woUld"'expect_ Jrom I hfitrbe KSvio'uF. One is sometimes 
surprised tHafpatlents to^"arr appearance wholly dull, have 
perceiv ed correctly all possible deta ils in their surroundings, 
kiTowThe names of their fellow patients, and notice changes 
in the dress of the physician. By more accurate observations, 
however, such as were carried out by Busch and by Gregor, it 
becomes evident that the extent and especially the trust- 
worthiness of perception are decidedly decreased. This is 
chiefly so in the acute phases of the malady, and then again 
in the last periods of its course. It was specially striking 
in the experiments of Busch to find that the patients usually 
made, a long wi^h a few correct statement s, a great many 
j^hoUy false on es. i:*or instance, in the perception of letters 
"rtrey uttered repeatedly the same arbitrary series or some- 
times parts of the alphabet. It was evident that they could 
not make the effort to retain and to reproduce what they 
really saw ; instead of this they named at random whatever 
happened to occur to them. 

Attention. — This behaviour is without doubt nearly re- 
lated to the disorder of attention which we very frequently find 

^ Albrecht, Allgem. Zeitschr. f. Psychiatric Ixvii. 659. 



6 DEMENTIA PRECOX 

conspicuously developed in our patients. It is quite common 
for them to lose both inclination and ability on their 
own initiative to keep their attention fixed for any length 
of time. It is often difficult enough to make them attend 
at all. The pat ients do not look up when spoken to, and 
betray riei t'HeF~byTbbk nor by demeanour in any way that 
they are sensitive to external impressions. )|Although this is 
so, they have 'perhaps perceived all the details, but have 
not experienced an)- real internal appreciation of their 
significance. \ Sometimes in cases of profound stupor or in 
many other insane states it is no longer possible, even by 
the strongest stimulus, to force the patients to show any 
interest. 

But the patients do not take any notice of what they 
may perceive quite well, nor do they try to understand it ; 
they do not follow what happens in their surroundings ev'en 
though it may happen to be of great importance for them. 
They do not pay attention to what is said to them, they do 
not trouble themselves about the meaning of what they read. 
On this depends what was ob.served by Ossipow in some of 
the patients, "photographic" reading, the thoughtless repetition 
of what is printed with all the signs of punctuation. 
Further there is seen the tendency of groups of patients, 
when they transcribe to copy carefully all mistakes, correc- 
tions, interpolations, and marginal notes. In psychological 
experiments the patients cannot stick to the appointed 
exercise ; they feel no need to collect their thoughts in the 
appointed manner, or to reach a satisfactory solution. 
Perhaps the experience related by Dodge and DiefendorfT, 
that patients do not usually follow a moving pendulum 
continuously, as normal persons do, but intermittently and 
hesitatingly, may be explained by a similar disorder of 
attention. 

With this loss of capacity to follow a lead is connected 
a certain unsteadiness of attention ; the patients digress, do 
not stick to the point, let their thoughts wander without 
voluntary control in the most varied directions. On the 
other hand the attention is often rigidly fixed for a long time, 
so that the patients stare at the same point, or the same 
object, continue the same line of thought, or do not let 
themselves be interrupted in some definite piece of work. 
Further it happens that they deliberately turn away their 
attention from those things to which it is desired to attract 
it, turn their backs when spoken to, and turn away their 
eyes if anything is shown to them. But in the end there is 
occasionally noticed a kind of irresistible attraction oj the 



PSYCHIC SYMPTOMS 7 

attention to casual external impressions. The patients 
involuntarily introduce into their speech words that they 
have heard, react to each movement of their neighbours, or 
imitate them. Leupoldt describes patients who instinctively 
had to touch or count objects as they came within their field 
of vision. On the disappearance of stuporous conditions a 
distinct inquisitiveness sometimes appears in the patients : 
they surreptitiously watch what happens in the room, follow 
the physician at a distance, look in at all open doors, but 
turn away if any one calls them. We shall later see that 
all these disorders of that inner activity of volition, which 
we call attention, represent only partial manifestations of 
general morbid changes in the processes of volition. 

Hallucinations. — Sensation is very often profundly dis- 
ordered in our patients as is evident by the occurrence of 
hallucinations. They are almost never wanting in the acute 
and subacute forms of the disease. Often enough they 
accompany the whole course of the disease ; but more 
frequently they gradually disappear, to reappear more dis- 
tinctly from time to time in the last stages. By far the most 
frequent are halluci?iations of hearing. At the beginning 
these are usually simple noises, rustling, buzzing, ringing in 
the ears, tolling of bells (" death-knell "), k^iocking, moving 
of tables, cracking of whips, trumpets, yodel, singing, weeping 
of children, whistling, blowing, chirping, "shooting and death- 
rattle " ; the bed echoes with shots ; the '_' Wild Hunt " makes 
.an uproar ; Satan roars under the bed. 

And then there develops gradually or suddenly the 
symptom peculiarly characteristic of dementia praecox, 
namely, the hearing of voices. Sometimes it is only whisper- 
ing, " as if it concerned me," as a patient says, a secret 
language, "taunting the captive"; sometimes the voices are 
loud or suppressed, as from a ventriloquist, or the call of a 
telephone, " children's voices " ; a patient heard " gnats 
speak." Sometimes they shout as in a chorus or all con- 
fusedly ; a patient spoke of "drumming in the ear"; another 
heard, ." 729,000 girls." Sometimes the voices appear to have 
a metallic sound, they are " resonant voices," " organ voices," 
or as of a tuning-fork. At other times they do not appear 
to the patients as sense perceptions at all ; they are " voices 
of conscience," " voices which do not speak with words," 
voices of dead people, " false voices," " abortive voices." A 
patient said : " It appeared to me in spirit, as though they 
would find fault, without having heard it." There is an 
" inner feeling in the soul," an " inward voice in the 
thoughts "; " it is thought inwardly in me "; it " sounded as 



8 DEMENTIA PR^XOX 

if thought "; " it was between hearing and foreboding " — 
in such ways the patients express themselves about these 
sensory disturbances. 

The illusions not infrequently are connected with real 
noises. The clock speaks as if it wore enchanted ; the 
rushing of water is changed into words ; each step under 
the patient speaks ; a patient " heard the thoughts of others 
out of the soles of his boots." Here and there the voices 
have a rhythmical cadence, probably in connection with the 
carotid pulse. 

The voices are often referred to the ear or the head ; they 
are "voices m the ear"; there are evil spirits in the ear, a 
telephone, a receiver, a phonograph in the head ; " the brain 
talks." One ear may be exclusively concerned in it, or at 
least more so ; sometimes the voices of the two ears have a 
different character. A patient asserted that the voices went 
in at one ear and out at the other. Many patients hear the 
voices in the whole body ; the spirits scream in the belly, in 
the feet, and possibly also wander about ; a patient heard 
them speaking in his purse. Another wrote down : — 

Voice in the right ear : " Never," for example as answer to a wish. 
Voice in the left ear: "Stupid — Jesus — God." \'oice in the stomach: 
" Blackguard. Point. Good." \'oice in the nose : " Munich ; Oho- 
boy." Voice at tfie heart : " Boy." Voice in the right side of the 
abdomen : " Yokel." 

But for the most part the origin of the voices is sought 
for in the external world. The patient feels himself influenced 
by the telephone, is a "living telephone"; "it all came by 
telephone to the bed "; said a patient. The question is 
about the " address," about " the communicated voices of 
human bemgs," about " murmurings and natural spirit- 
voices," about underground voices from the air, from the 
ground, voices from Further India and Siberia, whispering 
voices from the whole of mankind, " voices of spirits which 
are quite near," of God, the saints and the blessed, of the 
guardian angel, but especially of all conceivable persons in 
the neighbourhood. A patient heard a bird whistle from a 
picture ; another saw threads from which voices spoke. Often 
the voices torment the patient the whole day long, and at 
night also he hears " telephone gossip," or perhaps he only 
hears them now and then, not infrequently in the form of 
single detached remarks. 

It is, however, usually difficult to get trustworthy accounts 
of these occurrences from the suspicious and reserved patients ; 
they usually deny that they still hear voices, and only allow 
on pressure that yesterday or the day before perhaps some- 



PSYCHIC SYMPTOMS 9 

thing happened. Sometimes the patients are only able to 
give general information about the voices : " They were voices 
as if the battle was lost," " as if I had set about something "; 
" the conversation was about the king and royalty," " of life 
and the soul and divine love," of " marriage and death "; " the 
clergyman whispered something into my ear, that could not 
be understood." But much more frequently they catch the 
exact wording as in real perceptions ; some patients make 
notes of what they hear. 

What the voices say is, as a rule, unpleasant and dis- 
turbing. " The voices rushed in on me at all times as 
burning lions," said a patient. The patient is everywhere 
made a fool of and teased, mocked, grossly abused, and 
threatened. People speak about him ; everyone is occupied 
with him ; the whole workshop screams ; there is " a petty 
espionage," "like legal proceedings"; he hears voices, "as 
one reads of them in stories of murder and Indians." Some 
one calls out : " Rascal, vagrant, miserable scoundrel," 
"incendiary, parricide," "good-for-nothing," "blackguard," 
"anarchist, rogue, thieving murderer," "filthy fellow, filthy 
blockhead, filthy beast," "vagabond," "scamp," "swine," 
" filthy swine," " sloven fury,'' " town whore," " convict," 
"criminal, criminal," "offended, offended." The patient is 
said to have assaulted a child, seduced a girl with 80,000 
marks, had sexual intercourse with his children, eaten human 
flesh. He is threatened with having his ears cut off", his feet 
chopped off", with being sawn asunder, with being beheaded ; 
there is a command from the Government to stab him. " He 
must come along ; he must be arrested ; he has seduced the 
girl," it is said: 'That's he," "I've got him," "Wait, 
Kaiser Franz, we've got you!" "The fellow must go 
to the cemetery," " I'll shoot the convict through the wall," 
" J!lst come along, and you'll be killed," " Now we've given 
him a shot," "We'll do for him, he must come here," "We'll 
squirt water on him, we'll stab him," " He'll be milked," 
" There'll be an end put to the blackleg's children," " The 
beast's going to die, she's going to be fetched down, this 
creature." Most frequently they are indecent and filthy 
things that are called out in which impurity and self-abuse 
play a large part. In many of the utterances a certain 
feeling of disease comes to light. His comrades whisper 
secretly about the patient, saying that he is mentally affected, 
" an absolute fool," " He is studying, he has something in his 
head," " He has neurasthenia," " That is megalomania," " He 
must go the madhouse." 

On the other hand there are also frequently ^^ good voicesl^ 



lo DEMENTIA PRyECOX 

"good wishes," ''praise," "That's the real Simon Pure." God 
makes known to the patient that he will proclaim him, send 
him into the world as his son. " Here he is," cries a voice 
from heaven. He hears that he is a king's son, an officer's son, 
that Ue is very musical ; he has a splendid life ; " To-day 
we won't do anything to him." The voice calls out : " King, 
King ! " " Saint Joseph ! " " I am God "; a dove says at night : 
" You have already the divine bride." 

Many of the voices make remarks about the thoughts and 
the doings of the patient : " He has good hearing," " Damn it, 
what ears the fellow has!" "He has done for himself; the 
filthy fellow must get away from this," " Do you hear the 
reflector upstairs ? Now they have the sound-hole open 
again ": " Mary, you're talking nonsense, the policeman has 
seen you already," " But what have we done to him ? He 
never listens to us now," " The voices knew what I did," 
said a patient. Another when she exposed herself to the 
sun heard, " She is melting "; to one patient the voices named 
the people he met, "analysed his inside." They narrated 
events in his life, asked him about family affairs. "The 
director and the nuns disturb my rest at night, they tell me 
all that has happened in my life," complained a patient. 
" When I leave the house all the telephones know where I am 
going and what I am thinking of: the whole town is in 
excitement when I go out," said another. A patient who 
later became quite insane furnished the following notes : 

" In the Prince Charles I should have got a shilling tip — I should 
have been a conceited boy— The man would have been on his travels — 
Now the boy too is still laughing — Now Id just like to know why 
the boy is here — He's not yet at an end — Now I don't like it any 
more — O God! I'm sorry for the boy— He does write well — That 
goes on swimmingly — How well that all agrees — He writes each line 
in a different writing (The writing was really quite changed.) — iThe 
Jew can't help himself any more for discontentment — ". 

Often, however, in the beginning of the disease or in 
the more advanced stages what the voices say is indifferent 
or quite nonsensical and incomprehensible. The patient 
hears a call from England that he is to pay a visit, "always 
another way about, always new names"; he hears "Banker, 
rich farmer, crash, salt roll "; " Stallion," " They help me 
or they don't help me," The military come to-morrow early," 
" Education," " Lavender and crossroads are the stronge.st 
explosive," and similar expressions. 

From the very varied notes of a patient, who was quite 
sensible and rea.sonable, I give the following example taken 
at random — notes of his hallucinations which consisted of 



PSYCHIC SYMPTOMS ii 

detached sentences without connection, of the meaning of 
which in detail he was not able to give any account : — 

"She is said to have run after him — Oh you blockheads I always 
hear something and see nothing — I would just make a start — Get 
out with your trash — We have done our duty ; now he can do what 
he likes — It won't be finished immediately; if it goes far wrong, the 
law is still there— Get yourself licked at A. ; here you must have two 
ears, in at the one, out at the other, here the heirs can still wrangle, 
here twenty shillings, there twenty shillings, yes, why not? — How is he 
ever to think of it ; for he doesn't know what has happened— d'ye see 
him — shall we send him a servant— A tree isn't hewn down so 

Quickly ; it did not grow all at once, at night all cows are black — 
heating innkeepers — O, du mein lieber Augustin, 's Geld ist hin — 
Trees and the roots with them — Oh I must undress," and so on. 

Another patient, also quite reasonable, wrote down the 
following words as being what the voices said : — 

" He — veni — I came— Cham — Saul — Absalom — lyric — dropping — 
roast — lust — Turks — rukidiku — trilling— singing — tins — tinker — skr — 
ram — fail — dog — fruit — Ko — vault — complaint — flax— holy water — pasture 

— inspired — drone — dull — pressing — funnel — Druid — tremens — squeezing 
— dropping — quail— clever — formerly — sausage — lynx — vult— question — 
crime — splendour." 

In some places " veni — kam — Cham," " Saul — Absalom," 
" trilling — singing " — " tins — tinker," there is a certain con- 
nection, if only external, of the ideas which follow each 
other. But, except for these, the words are connected 
without any obvious link of ideas or sound ; at most the 
slight similarity of sound in " roast — lust " and in the series 
" drone " to " dropping " [in German, Drohne — triibe — drangen 

— Trichter — Druide — tremens — driicken — tropfeln] could 
be regarded as the connecting link. This series reminds 
one of similar inventions of alcoholics in delirium when 
they read from a blank sheet of paper ; and in reading 
during dreams such expressions, wholly without connection, 
occur. 

Many patients hear perpetually, in endless repetition or 
with slight changes, the same meaningless sentences, so 
that there is a kind of hallucinatory verbigeration. The 
following notes give an example of it. They were written 
down by an otherwise thoroughly clear and intelligent 
patient : — 

" For we ourselves can always hope that we should let ourselves pray 
other thoughts. For we ourselves wish to wish to know who would let 
the swine's head be tormented to death with us foolishly. No, we our- 
selves are no longer so stupid, and do not always trouble ourselves, if we 
shall let ourselves be spared drinking like beasts. Because we just 
behave as fools and would let ourselves be cheated like silly swine." 

In a series of cases the voices give commands which in 
certain circumstances are very precisely obeyed. They 



12 DEMENTIA PR^ECOX 

forbid the patient to eat and to speak, to work to go to 
church ; he must run barefoot. " Go on, strike him, beat 
him," it is said, "go on, go on!" "Hands up!" "Slope 
arms!" "Put the chair here, stand up!" "Jump in!" 
A patient said that he heard : " You must do that," then 
" You must not do that " ; " it is a chaos, one can't get out." 

But it is quite specially peculiar to dementia praecox that 
the patients' own thoughts appear to thevi to be spoken aloud. 
In the most varied expressions we hear the complaint of the 
patients constantly repeated that their thoughts can be per- 
ceived. They are .said loud out, sometimes beforehand, some- 
times afterwards ; it is " double speech," the " voice trial," 
" track-oratory," the " apparatus for reading thoughts," the 
" memorandum." A patient heard her thoughts sounding out 
of noises. In consequence of this everything is made public. 
What the patients think is known in their own homes and is 
proclaimed to everyone, so that their thoughts are common 
property. " I have the feeling, as if some one beside me said 
out loud what I think," said a patient. " As soon as the 
thought is in my head, they know it too," explained another. 
" When I think anything I hear it immediately," said a third. 
People look into the brain of the patient, his " head is 
revealed." When he reads the newspapers, others hear it, so 
that he cannot think alone any longer. " We can read more 
quickly than you," the voices called out to a patient. " Every- 
one can read my thoughts, I can't do that," complained a 
patient. Another said, " A person can have his thoughts 
traced by another, so that people can learn everything." A 
patient himself had " to whistle " his secrets " through his 
nose." 

Influence on Thought. — Still more characteristic of the 
disease which is here discussed seems to be the feeling of 
one's thoughts being influenced, which often occurs. People 
speak to the patient in his thoughts, guide them, contradict 
him, "offer" him thoughts, suggest them to him, transfer to 
him words, thoughts, pictures, smells and feelings. A patient 
said, " My senses dont belong to me any more, they are 
being unlawfully taken from me." Strangers send him 
thoughts silently and speak in his head, it is " a remembrance, 
a memory, a memorial," a "receiving of thoughts." In this 
way his own thoughts are disturbed, "drilled," " drawn off" ; 
he cannot think when the voice speak.s. A patient explained, 
" They take my thoughts from me and nothing comes back 
but a ragamuffin." What he thinks himself is distorted ; his 
thoughts are " plundered, organi.sed and published." " The 
voices and my brain are one, I must think what the voice 



PSYCHIC SYMPTOMS 13 

says," said a patient, and a woman complained ; " The voices 
work on my thoughts from morning to evening, suggest 
dreams to me and torment me unceasingly." Many of the 
patients must utter aloud their own thoughts or those that are 
given to them, " low by movements of the lips," " say silly 
stuff to oneself." " It flows into the brain as a thought and 
expresses itself as words in the mouth," said a patient. 
Another heard " dead " and had to answer " bread." 

On the other hand the patient sometimes knows the 
thoughts of other people, is " connected by telephone with 
M'Kinley," can " speak with the Kaiser," " tones constantly 
with God," " is in constant communication with the Holy 
Ghost." He can also think for others, he passes on the thoughts, 
carries on conversations, dialogues, with his companions^ 
with people in other houses ; it is an " electrical glee." 
" There is talking going on in my head and body," said a 
patient. " I close my throat and sing the most beautiful 
songs, and you do not hear it." 

These most extraordinary disorders, quite foreign to 
healthy experience, are at first usually kept secret by the 
patient, so that one only hears something about them when 
they have already existed for a long time. The patients 
frequently connect them with malevolent people by whom 
they are " watched through the telephone," or connected up 
by wireless telegraphy or by Tesla currents. Their thoughts 
are conveyed by a machine, there is a " mechanical arrange- 
ment," " a sort of little conveyance," telepathy. A patient 
said, " I don't know the mati who suggests that to me." 
Another supposed that it might perhaps be done for scientific 
purposes by a professor. vA third explained, " I am perfectly 
l Y >sane and feel myself treated as a lunatic, whjleTTaTTucinatlohs 
are "brougKt to me by magiietlsifnSncl erectriclty."^ Or thff" 
patients think of supernatural powers, of " demi-spirits which 
perceive the thoughts," " little souls and little figures," their 
guardian angel, God and Christ ; they are inspirations,, 
revelations. A patient heard the unborn Virgin Mary speak 
in his belly ; another carried God's voice in his heart. 

Many patients feel themselves very much troubled by 
telephony, they stop their ears, " do not like such treatment 
by voices." One patient begged that " the blessed nonsense 
should be taken away." Others regard themselves as 
specially privileged. " I hear from a distance ; not everyone 
can do that," said a patient. Some patients try, by ingenious 
devices, to protect themselves against their thoughts being 
influenced ; a patient translated foreign words in order to 
ward off the receiving of thoughts. Others exert themselves 






14 DEMENTIA PRECOX 

to conceal their real line of thought to a certain degree, by 
a second carried on alongside of it, which shall then receive 
the outside influences. 

Hallucinations of sight begin with variegated rings in 
front of their eyes, plays of colour, fiery rays and balls, seeing 
sparks, everything looks awry and wrong. The patients are 
troubled by reflections, by blinding light, their eyes are 
irradiated and blinded by reflectors. On the wall appear 
white figures, reflections, the mother who is dead, paintings, 
imaginative pictures, death's heads, a heart with a dagger, 
ghosts, shadow figures half beast, half human, southern 
landscapes, saints from all eternity ; it is photography at a 
distance and double sight. In front of the window a clown is 
tumbling about, good and evil spirits appear, angels and 
the Virgin Mary in a blue mantle offer the cup, Satan with 
horns and a fiery tail dances about the room, death appears 
as a figure with a mask ; at night men approach the bed. 
Black birds of prey hover overhead ; people appear who are 
not there; the Emperor ofChina comes and speaks; gentlemen 
in white suits, lions, people who are dead, pretty girls, red 
men with black heads appear ; a black figure grins. The 
patient sees " a shining crown and a threatening star," 
" theatrical stuff," naked women, improper pictures, an 
automobile in the air, two men in a balloon, the " Wild 
Hunt" ; a green shadow flies beside him. There are snakes in 
his food, in the water for his bath. Supernatural appearances 
are seen in the air, fire in the sky, a halo, Luther in the 
clouds, spirits in the fields. Acquaintances look strange, 
everything is as though accentuated, pieces of furnitnre are 
changed into the form of wife and children ; the figures in 
paintings and sculpture make obeisance. A patient saw the 
" voices " in the form of small, grey, four-footed beings hopping 
round about and whirling in the air ; they were accompanied 
by small flames, which could be separated from them, 
Another offered in a very definite way " extrakampine " 
hallucinations; he " saw " a gun-barrel on his back, led and 
white mice in his heart, two tortoises in his shoulder. 

Smell and taste frequently share in the morbid condition. 
Evil smelling substances are scattered about; there is a smell 
of sulphur; of corpses and chloride of lime, of blood, of fire, 
of the fumes of hell, of "stinking poison," of dynamite. A 
patient smelled human souls ; another felt the devil standing 
behind her, ' it stank." Cold vapours are blown in at the 
one nostril, warm vapours at the other. Many patients smell 
the fragrance of roses, or notice that they are being 
chloroformed or stupefied by perfumed handkerchiefs. The 



PSYCHIC SYMPTOMS 15 

soup has a curious taste of creosote ; in the food there is 
petroleum or arsenic, in the beer morphia or iodoform, the 
drinking water is brackish, or contains chloroform. 

Morbid tactile sensations and common sensations mean- 
while gain considerable importance in the clinical picture. 
They are usuall) very varied. The patient feels himself laid 
hold of, touched over his whole body, he feels tickling in his 
thigh and right up to his neck, pricking in his back and 
in his calves, a curious feeling in his neck, heat in his 
face ; hot sand is strown over his face, filth is put in his 
hair; something is squirted on his feet; a hundred mice run 
over his neck. At night he is pricked with needles, he gets 
blows in the ribs, invisible powder is sprinkled over him ; 
warm air plays on his body. He has a feeling as if his feet 
were rising from the ground ; his bed is pushed at night, 
moves about, swings. Vermin and itch powder are in his 
bed ; a patient felt lion cubs. There is a tearing feeling in 
his head and in his back, a burning in his stomach, pain in 
his teeth, a rolling in his brain, a tugging at his heart, lumbago 
shoots through his body and loins. A patient felt it in his 
right ear, if other people turned up their noses. 

Not infrequently these imaginations, connected apparently 
with organic sensations, receive a very strange interpretation. 
The patient is terribly tormented in his body, notices that 
something is taken away from him, blood is taken, that 
"every part of his body is misused"; he feels "internal 
stirrings." emptiness inwardly, currents and strains in his 
body. Water flows away out of his body, food goes 
immediately out at his head. His body is twisted ; his 
mouth is torn asunder ; his gums are broken open ; his eyes 
are clawed out ; his hair is tugged out ; his shoulders are 
pulled apart, his testicles are burst ; her ovaries and stomach 
are torn out ; his cheeks are pared off. His brain is crushed, 
his throat is blown out ; his whole intestine is drawn up ; fire 
bursts out at his mouth. The patient has injections made 
behind ; God pierces his foot with a wire ; he is disfigured. 
A man is laid across him, his back is broken, his breath is 
sucked up. Ears and head are blown up, his strength is 
drawn out, his toes are burned off, his ears are cut off. A 
patient kept saying that he was being "deprived," another 
that he was being "undone." A third complained of "inter- 
sections "; a fourth said, " It is always as if something were 
being shoved into me," a fifth felt " a thousand dolls sliding 
down inside him." 

Very commonly these sensations are associated with 
electricity and similar action at a distance. The patient feels 



i6 DEMENTIA PR/ECOX 

himself fastened to the receiving and also to the discharging 
station, electrified from a distance, raised from the ground by 
electric shocks, blown up by electricity, he feels the current in 
his pleur.t, a prick in his heart from the apparatus, he becomes 
warm by the rays ; electric currents flow through his bed ; an 
electric current comes from the sun. A patient thought that 
she was illuminated with Rontgen rays under her petticoats 
and was thus exposed to the general gaze. 

As the result of these hallucinations the conviction is 
often developed in the patients that they have become the 
sport of all sorts of influences} A patient described this in 
writing in Lhe following words : — 

" I felt myself touched in such a way as if I were hypnotised, 
electrified, or generally controlled by some sort of medium or some other 
will. My several organs of sense were influenced in such a way, that I 
always heard the will of the medium from great distances, to which I had 
then unconditionally to surrender myself I feel and hear the will in 
all parts of my body, in my whole organism. I must do what I hear 
according to the will of the so-called medium which can assume the voices 
of all people known to ine, of whom others daily appear before my soul. 
In this way as regards my person there are no secrets for the medium as 
a whole. Ail that has passed through my brain, or that still influences it, 
is reproduced by the medium, and indeed as often as it likes, and my 
brain has always to take part in this proceeding, which extends not only 
to thoughts but also to speech. The characteristic feature is that I 
also have these hallucinations of hearing when my hearing is deafened 
by a real noise, so that I am sure that these proceedings take place in 
the brain itself I have also already had hallucinations of sight, visions,^ 
and all this happens according to the will of the medium and as a 
consequence of my power of imagination. The visions only appear 
when I have my eyes closed." 

Notice here the curious mixture of insight into disease 
and ideas of influence, but especially the feeling of internal 
compulsion, which we shall meet with again and again in our 
descriptions. 

Sexual sensations play a considerable role in our 
patients' experiences. The patient has a feeling of contraction 
in the testicles and penis, experiences " a sultry feeling " on 
meeting people, notices signs in his fingers which the girls 
make. Love-charms are employed, the penis is erected by 
the electric current, a gold needle is stuck into it. At night 
lustful deeds are committed, his nature is electrically with- 
drawn from him ; lustful men approach him. A patient felt 

'Haslam, Erklarungen dcr Tollheit, Ubersetzt von Wollny, 1889; Wollny j 
Uber Telepathic, 1888; Sammliing von AktenstUcken. 1888; Teffer, Ul>er die 
Tatsache des psyclio sexuakn Kontaktes oder die actio in Distans. 1891 ; 
Schreber, E>enkwlirdigkeiten eines Nervenkranken. 1903. 



PSYCHIC SYMPTOMS 17 

that she was kissed at night by a Capuchin. Another patient 
described her experiences at night in the following way : — 

"It seemed to me in the night as though I were divinely and 

spiritually married, or rather that my innocence was taken from me. 

The pains were considerable, but I did not scream though for some 

minutes I had to breathe violently. It then seemed to me as though I 

,were several times married, when I had to lie down on the bed with 

' better clothes on. But there never was a human being with me." 

Orientation is not usually disordered. The patients 
know as a rule where they are, recognize people, are clear 
about the reckoning of time. It is only in stupor and in 
states of intense anguish that the correct perception of the 
environment may occasionally be more profoundly disordered. 
Jt is indeed often just the characteristic of th^ p^^^ ipntt; that 
t hey remain sur prisingly clear m spite of the most ^i o lcU i r 
excitement. On the otReFhand, however, orientation Is not 
iiifrequeiTtly encroached upon by hallucinations. The patients 
name their place of residence and persons incorrectly, give a 
wrong date, are in a wrong hospital, in an imitation* madhouse, 
in a prince's house ; the physician is God, the attendant 
Satan ; his relatives have been exchanged, his fellow patients 
are females or disguised policemen. But here it is clearly 
not a case of falsification of perception but of insane 
interpretation of impressions in themselves correctly per- 
ceived. 

. The consciousness of the patients, if we leave out of 
account the terminal condition of dementia, is in many cases 
clear throughout. Only in conditions of excitement and 
stupor is It occasionally dulle d, though the dulness is not 
'usually so great as it appears at the first glance. The patients 
complain frequently of passing dulness of consciousness 
which should probably be regarded as a condition of very 
slight stupor. They say that they were " stunned," " dis- 
embodied, magnetically repressed "; they became suddenly 
incapable of thinking or of working. These are " mental 
conditions a rtificially induced through hypno sis," "spiritual 
visitations," " magneti c condittnns ot siee p.^^ caused by the 
physician* A pa'tlenfthought he suffered from "somnam- 
bulism " ; another narrated about the " nightly narcosis 
with Rontgen in which she was cross-questioned ; it would 
all appear in the newspaper in which people would hear 

wabout it." 

v Memory^ is comparatively little, d is ordere d. The patients 
are able, when they like, to_ give a correct detailed acco unt 
of their past life, and often know accurately to a day how 
1 Gregor und Hansel, Moratsschr. f. Psychiatric, xxiii. i. 



i8 DEMENTIA PR/ECOX 

long they have been in the institution. JThe knowledge 
which they acquired at school remains Sometimes with 
surprising tenacity until they are sunk in the most profound 
dementia. | T remember a peasant lad, mentally quite dull, 
who could point to any town on the map without hesitation. 
Another startled you by his knowledge of history. Others * 
again solve difficult problems in arithmetic with ease. 1 
Weygandt ascertained that a prebendary of the Julius 
Hospital, who suffered from mental disease and was quite 
confused, still retained forty-seven years after the beginning 
of his illness a fair knowledge of Latin, mastery of the 
multiplication table, and also recollected all sorts of historical 
facts, although these ideas had certainly not been roused 
for decades. 

Retention is also often quite well preserved. Gregor 
however, found in his experiments very dissimilar values for 
successive repetitions in consequence of great wavering of 
attention. Mistakes and senseless combinations were not 
corrected, 'but rather showed an inclination to become 
established ; continuance of the repetition was of com- 
paratively little use. Vieregge also reports great wavering 
of attention. In spite of that it is usually easy to impress 
numbers or names even on quite indifferent patients, which 
they correctly reproduce after days and weeks. llCertainly 
inappropriate answers are often given first, but after more 
searching interrogation it is clear that the patients have quite 
understood the exercise. I After deep stupor it sometimes 
happens that the patients have no recollection, or only a very 
dim recollection, of what has occurred during a long space of 
time, it may be that because of the dulness of consciousness, 
they were unable to perceive, or that the impressions were not 
permanent. 

Pseudo - memories. — Here and there we meet also with 
confabulations which point to pseudo-memories. It must, it 
is true, seem very doubtful if one ought to speak of such when 
the patients relate that they have been in hell, in heaven, in 
America, have travelled over the moon and all parts of the 
world, that at six years of age the marrow was burned out of 
their legs, and their feet were chopped off". A patient 
declared that he had already been beheaded, but his head had 
not fallen off". In other cases, however, it is easier to assume 
pseudo-memories. The patient remembers having been in a 
beautiful castle as a little child and having sat on the knee of 
a grand gentleman, and to have been kidnapped on a 
cloudy night. Kaiser VVilhelm on a journey through the 
town gave him a medal which in an unaccountable way has 




PSYCHIC SYMPTOMS 19 

been mislaid. Others assert that they already knew before- 
hand where they were to be brought, and what would happen, 
that in the madhouse they would meet this and that person, 
that there would be a fire, and they would get a bride. A 
patient asserted that the Spirit had prophesied to him the 
death of an acquaintance ; another explained that God 
inspired him so that he could foretell what should happen. 
Or the patients think that they have already been in the hall, 
that they have seen the pictures before ; they consulted the 
physician once two years ago. A patient declared he had 
himself planted the trees in the hospital garden. Usually the 
tendency to such insane pseudo-memories passes off quickly. 

Train of Thought. — This sooner or later suffers consider- 
ably. There is invariably at first a /oss of inetital activity and 
therewith a certain poverty of thought. The patient " has 
little life in him "; his nerves are under sucFT^skm^thar he 
can no longeFthink or speak. Thinking is difficult to him ; 
" he trifles about the whole day," occupies himself "with tear- 
ing off the last leaf of the calendar and tidying up." His 
thoughts have been taken out of his head ;,he has lost the joy 
of life ; it is as if a fur cap were on his brain, he is " as stupid 
as a pig "; his head is empty and hollow. A patient 
complained that "he had no more earnestness." 

Association experiments. — Bouman frequently observed 
repetition of the word used as stimulus, irrational associations, 
omissions ; disinclination to make the attempt seemed to 
lay a considerable role. Bleuler brings forward, among 
thers, as further peculiarities of "schizophrenic" associa- 
tions, great irregularity of association-time, connecting up 
with former stimuli or answers, frequent repetition of the 
same associations, tendency to indirect associations, change 
of answer on repetition of the experiment. Marcus found in 
his patients specially livelyvisual ideas. Further, Pfersdorff 
has proved that in the combination oF ideas lifigtiistic con- 
stituents gain a certain preponderance ; the patients show a 
tendency to rhym e, t o intjpduce asso!TatT £gs, to play witiT 
word s, t o tm st Hi^m, Kehav-iour to winch we shall later have 
\o return" - 

But above all, as Bleuler especially has shewn in detail, 
the patients lose in a most striking way the _faculty of logical 
ordering of their trains of thouc rht. On the one hand, the 
most selt-evident and tamiliar associations with the given 
ideas are absent. It seems as if these were only partially 
illumined, and therefore were not in a position to call into 
consciousness thoughts that lie quite near. On the other 
hand again, the most unnatural combinations of heterogen- 



20 DEMENTIA PR/ECOX 

cous ideas are formed, because their incongruity is not 
perceived on account of some purely external relation, as 
similarity in sound, or coincidence in time. The most evident 
truths are tiotrecogiiised, the gr eatest ^coptradictions ^e 
thoughtlessly accepted. " DocTor, Is your name Julia?" asked 
a"7^atienT7^TTff another called the physician "Mrs Colonel." 
By these disorders, which in many respects remind one of 
thinking in a dream, the patients' mental association*; often 
have that peculiarly bewildering incomprehensibility, which 
distinguishes them from other forms of confusion. It con- 
.stitutes the essential foundation of incoheren ce of th ought. 

In less severe cases this is shovvn~oTTty-TTrTncreased facility 
of distraction and increased desultoriness, in passing without 
any connection from one subject to another, in the interweav- 
ing of superfluous phrases and incidental thoughts. Similarly, 
Pfersdorff found in continuous reading a tendency to make 
meaningless mistakes, ^^o perseveration of ce rtain words, to 
changes and omissions7~even when single words or short 
sentences were correctly rendered ; he concludes rightly that 
there is a failure .of attention. A patient who was quite 
sensible, when asked to copy the fable of the " greedy dog," 
performed the exercise correctly as far as the sentence : " But 
when he snapped at it, his own piece of meat fell from his 
mouth, and sank in the water," then, however, continued : — 

".And as now her present condition depends wholly on what Dr 
J. M. plans for the future, who wishes to make himself acquainted with 
what is in connection with it, and of whose condition she wished to be 
again acquainted with, which he wished on his own desire. Now he had 
nothing at all but what was yours, which seems to lose what was his, but 
he himself tried to lose it, the fortune which for him was trying to be 
acquired," and so on. 

The line of thought here leaves the appointed exercise 
and moves in indistinct spheres of ideas, which otherwise 
occupied the patient, and then, without any connection, again 
brings in parts of the fable (" Now he had nothing at all," 
" Who wants to take the goods of others loses his own "). 
Still more striking is the departure from the given idea in the 
answer of a patient who was asked what year it was : — 

"O I know nothing, what shall I say? Fire, fire ! O you old beast, 
devil, wretch, dog, slaughtered, slaughtered I It's cold in the wood ; 
hurrah ! Damn it a million times, beast of a cat, slaughtered I " 

In certain circumstances the incoherence may go on to 
complete loss of connection and to confusion. An example 
of this is given in the following answer of a patient to the 
question : Are you ill? — 

"You see as soon as the skull is smashed and one still has flowers 
Maughs) with difficulty, so it will not leak out constantly. I have a sort 



PSYCHIC SYMPTOMS 21 

of silver bullet which held me by my leg, tiiat one cannot jump in, where 
one wants, and that ends beautifully like the stars. Former service, 
then she puts it on her head and will soon be respectable, I say, O God, 
but one must have eyes. Seats himself and eats it. Quite excited, I 
was quite beside myself and say that therefore there should be meanness 
and there is a merry growth over. It was the stars. I, and that is also 
so curious, the nun consequently did not know me any more, I should 
come from M. because something always happens, a broken leg or 
something, they've had a quarrel with each another, the clergyman and 
she ; a leg has just been broken. I believe it is caused by this that such 
a misfortune happens, such a reparation for damages. I have also said 
I shall then come in the end last, with the sun and the moon, and too 
much excitement, and all that makes still a great deal of trouble. Kings 
do not collect the money, "in this way the letters have been taken away 
from me, as I at last specially think from the that, and all are burned. 
You can imagine that comes always from one to the other." 

In a few places here, a certain connection between the 
ideas can perhaps be recognised : — " ill — skull smashed," " held 
by my leg — not jump in," "something happens — broken leg," 
"misfortune— reparation for damages," "excitement — trouble," 
"letters taken away — burned," "excited — quite beside my- 
self" Also "silver bullet" and "stars," and further on "sun 
and moon " and " nun " and " clergyman," who " have had a 
a quarrel with each other," point to associations of thought. 
On the whole, however, we have before us a completely 
unintelligible and aimless series of words and fragments of 
thoughts. It must certainly be taken into consideration that 
the actual train of thought is possibly much less disordered than 
the expression of it in speech, because the patients, as indeed 
happened in this case, can in certain circumstances not only 
perceive correctly, but also further elaborate what they per- 
ceive and behave fairly rationally. 

Stereotypy. — We almost al ways meet in the train of 
thought of the patients indicatlons^of " stefebfypy, oFThe 
persistence ,ot_g ingIe id eas. If "thfe^ patient continues talking, 
the same ideas^nd expressions usually turn up again from 
time to time. Occasionally the persistence gets the mastery 
of the train of thought to such an extent that the patients for 
weeks and months always move in the same monotonous 
^sphere of ideas, and cannot be brought out of it by any 
means. ~ 

Evasion. — Further peculiar disorders of the train of 
thought which here and there are observed, are evasion and 
a feature which Bleuler more accurately characterised as 
"^utdlectual nega tivisvir Evasion or paralogia consists in 
tRis,lTiat the Idea which is next in the chain of thought is 
suppressed and replaced by another which is related to it. 
It appears most distinctly in the patients' answers to 
questions ; but it might be possible that the complaints of 



22 DEMENTIA PR/ECOX 

the patients that their thoughts are "drawn ofl " from them, 
"distorted," refer to similar occurrences. An example is 
given in the following answers of a patient to the physician's 
questions : — 

What is the name of this gentleman? (Dr A.), " Little man." What 
is his name.'' " Floischiitz" (The name of a fellow patient). How many 
fingers am I holding up? (3) "Four." How many now? (4) "Five." 
And now? (2) "One." How much money is that? (three pennies) 
'* .Si,xpence." No, you know quite well, "Twopence," No, how much? 
" Fourpence." Now name the number that was left out, how much 
then? "Twenty-five thousand." What do you mean by twenty-five 
thousand? "That I'm all right." 

It is here easily seen that the patient deliberately 
avoids the right answer which he certainly has at his 
command, a proceeding which at first makes the impression 
of intentional dissimulation. A patient replied to the 
question how old she was ; " One day." Clearly this 
phenomenon is nearly related to the negativistic disorders 
of thought. They appear in the difficulty to carry on a 
series of ideas as one wishes, the patient's thoughts are 
" taken " from him. So it sometimes comes to pass that he 
is obliged to think the opposite of what he really wishes. 
There are "quarrels in his head." One patient said, "My 
ideas have quarrelled," while another, perhaps with reference 
to such occurrences, said, " Swindling is constantly going on 
in my inside." This state appears more clearly in the 
utterances of other patients, that they " are forced to think 
otherwise, " that they " have to think the opposite of what 
other people with normal understanding do." 

Constraint of Thought. — From these and similar 
experiences the feeling which has already been discussed 
often develops in the patients, that their thinking is con- 
strained, has been withdrawn from the dominion of their 
will by irresistible influences. On the one hand thoughts 
arise in them which they feel as strange, as not belonging 
to themselves ; there is a " thronging of thoughts," a " pushing 
of thoughts." .sometimes in tempestuous form. A patient 
had to " drive through his brain in four hours nineteen jears "; 
another thought he would have to write a book if he were 
to note down everything that came into his head. But on 
the other hand the patients cannot think as they wish ; their 
thoughts are withdrawn from them, slip away from them, 
although they exert themselves to hold them fast and to 
think them out. Owing to this there can be a sudden 
"blocking" of their thought, producing a painful inter- 
ruption in a series of ideas. 

They never tire of describing this con.straint of theirs 



PSYCHIC SYMPTOMS 23 

in ever varying ways. The patient's thoughts are influenced, 
inspired, pressed on him ; he must receive them like a tele- 
phone ; they are forced on him by hypnotism and suggestion, 
act on him " by suggestion." Everything that he thinks 
or says is thought or said under compulsion. A patient 
had always to fight against the idea that he was Christ. 
Reading is interrupted by thoughts and explanations ; 
thoughts are arrested, blurred, the patient has to exert 
himself to squeeze them out ; he must think what people 
say. He feels as if his brain stood still, as if he had two 
brains. He is no longer himself, he has a kind of double 
consciousness ; the voices pull a thread, so that he has to 
think such stupid things. The thoughts can be taken out 
of people's brains ; the patient is confused in his head, he 
cannot grasp any clear ideas, he cannot bring order into 
the jumble of his thoughts, there is an "entanglement in 
his mind." A patient wanted to strangle herself because 
she had not her thoughts any longer. Thoughts are made 
by others in the distance, in Berlin, read off, taken away, 
carried over. "It was blown into me that way" said a 
patient. His thoughts escape from the patient, he cannot 
catch them up, he is no longer independent. A patient " had 
to speak about politics," another had always to think of 
" business arrangements," a third " had to despise people." 
Frequently, as before described in detail, the powers which 
carry out such thought-influences, take on the form of voices 
which take away, turn aside, or suggest thoughts. 

Mental efficiency is always diminished to a considerable 
extent. The patients are distracted, inattentive, tired, dull, 
do not take pleasure in work, their mind wanders, they lose 
the connection, they " cannot keep the thought in mind," 
they have no perseverance. I It is true they are often able 
to carry out quickly and correctly tasks depending solely 
on, memory or practice, sums, repetition of what they have 



previously learned, but fail completely as soon as it is a 



^i/ 



mentioned. In work the patients soon become negligent, 
they get bad certificates, pass no examinations, are turned off 
everywhere as useless, and easily fall into the condition. of 
beggars and vagabonds. They sit about idle and the most they 
do is to turn over the pages of an old calendar or to stare 
at the advertisements in a newspaper. Others develop great 
diligence, " study all night long," but accomplish nothing at 
all, take up trifling or aimless occupations, begin to compose 



24 



DEMENTIA PR/ECOX 



bombastic, incomprehensible rhymes, to copy a foreign 
dictionary, or they lock themselves up in order to learn 
poems off by heart. 

Experiments in calculation yield further insight into the 
changes in mental efficiency. These experiments were 
employed in a number of patients according to the procedure 
formerly employed for alcoholics. Fig. i gives a graph of 
the results. Here the work done in the first five minutes 
and in the second five minutes, on the days when no pause 
was made, is represented by a continuous line ; the value of 
the second five minutes, on the days when a pause was 



100 




i~ 
























99 




i 
























98 




I 
























97 




\ 
























96 




\ 
























95 




\ 




i 




1 
















94 




\ 




/ 




1 
1 


I 
1 














93 






V» 


/ 




1 


1 














9? 






N 






1 
1 
















91 












1 
















90 












1 








/ 








89 














^ 






/ 








88 












If 


1 




J 


r 








87 












1/ 




\ 1 


7 


\ 








86 


















/ 


\ 








85 


















/ 










84 






















r- 


83 
























1 23456709 10 



Fig. I. Calculation tests in Dementia Pnecox. 

made, by a broken line, while the average work done in the 
fir.st minute is. put down at a hundred. We recognize in 
the first place that the values in the first part of the experi- 
ment sink very much more quickly than in the directly 
comparable normal attempts, a behaviour, that may be 
caused either by specially great liability to fatigue or 
through very rapid yielding of the original will-tension. 
The striking oscillations of the values of the average 
minutes particularly in the second part of the curve as also 
the high values attained even here in single minutes (sixth 



PSYCHIC SYMPTOMS 25 

and tenth) is in some measure contrary to the assumption 
of unusually great effect of fatigue. It is still more decidedly 
disproved by the insignificance of the general effect of the 
pause which we know may be regarded within certain limits 
as the measure of fatigue. The work performed rises 
considerably, it is true, in the sixth minute on the days 
when there was a pause, but sinks again immediately and 
keeps after that within the limits of the values reached on 
the days when there was no pause. Comparison with the 
curves of normal persons and still more with those of the 
very easily fatigued alcoholics shows quite distinctly the 
difference in the effect of the pause. The even and rapid 
fall of the values in the first beginning of the task, as well 
as immediately after the pause, points here also to a very 
rapid yielding of will-tension, as in alcoholics, but it is not 
connected with heightened liability to fatigue, but with the 
•direct and very considerable oscillations of the work done, 
which clearly correspond accurately to the oscillations of 
attention observed by Busch and Grcgor which also usually 
appear in the clinical picture. 

Judgment. — Further the faculty of judgment in the 
patient suffers without exception severe injury. What 
always surprises the observer anew is the quiet complacency 
with which the most nonsensical ideas can be uttered by 
them and the most incomprehensible actions carried out. 
It is true that they often -move with tolerable certainty in 
accustomed paths, but in t-he psychic elaboration of new 
experiences, in the judgment of circumstances not hitherto 
experienced, and in particular of their own state, in the 
drawing of obvious conclusions, in the bringing forward and 
trial of objections, they not infrequently commit the grossest 
blunders. One has the impression that the patients are 
not in a position to accomplish that mental grouping of 
ideas which is requisite for their survey and comparison, 
their subordination among one another and for the discovery 
of contradictions. In this respect they resemble dreamers 
in whom likewise the ability to sift the ideas which come 
into the mind, to arrange them and to correct them accord- 
ing to the standards gained by former experiences and 
general ideas is abolished. These disorders, on whose great 
fundamental significance Bleuler also lays most emphatic 
stress, suggest an encroachment on the inner action of will. 

The patients often have a distinct feeling of the profound 
change which has taken place in them. They complain 
that they are "dark in the head," not free, often in confusion, 
no longer clear, and that they have " cloud thoughts." 




26 DEMENTIA PRECOX 

They cannot grasp a thought, cannot understand anything ; 
their mind is scattered ; their thoughts have flowed away ; 
their brain is no longer competent, is enfeebled. " My 
thoughts went away and will never come back," said a 
patient. " My mind has been taken away by spiritual 
influence of speech and will." " My whole mental power 
has disappeared, 1 have sunk intellectually below the level 
of a beast," " I am quite out of my mind," " I am being 
punished a little by my imagination," " I have become very 
stupid lately," " I've got something in my head," " My mind 
sometimes goes away," "The stupid fellow is confused," are 
similar expressions. Others call themselves "Half-fools" 
"easily weak-minded," "idiotic"; they are afraid they are 
going out of their mind, becoming insane, falling ill of 
softening of the brain. " Things go round about inside ine, 
thoughts which belong to a sanatorium," said a patient. 
Another said that he had lost the faculty of perception and 
energy, that he was wholly changed. A patient declared 
she was quite well, but stupid, and would like to be cured, 
while another begged that she might be freed from spirits, 
she did not wish to be mad, to be the plaything of other 
people, but wished to be like other human beings, she couldn't 
stand it any longer, she was quite incurable. Many patients 
begin to read medical books, connect their complaint with 
onanism, begin all sorts of cures. A patient was absorbed 
in the books ; " How Can I Become Energetic ?" and " Guide 
to an Imposing Appearance," and he diligently carried on 
medical gymnastics, deliberately gazing at the sun as long 
as possible every day in order by so doing to improve his 
health. In contrast to these indications which sometimes 
characterize the situation with surprising clearness, under- 
standing of the disease disappears fairly rapidly as the 
alady progresses in an overwhelming majority of cases 
even where in the beginning it was more or less clearly 
present. 

Delusions, ^either transito ry or permanent, are developed 
with extraordinary frequency on the foundation of the morbid 
change which is created by dementia praecox. In the first 
period of the disease they are usually by preference of a sad 
character, hypochondriacal, or ideas of sin or of persecution.-^ 
TRe feetmg of disease takes on insane forms ; the brain is 
burned, shrunken, as if completely gone to jelly, full of water, 
the mind is " drawn like rags from the brain " ; the patient 
" has only a little knuckle of brain left " ; the nerves are 
teased out. The tongue is made of iron, the lungs are dried 
up, blood is in the spinal marrow, wax in the body, the heart 



PSYCHIC SYMPTOMS 27 

is dried up, the flesh is loosened from the bones, the blood 
vessels tremble, threaten to fall down, the spinal marrow runs 
out by the genitals. The patient is not a human being any 
longer, he has not got his life any more, carries a death skull 
in his head, gets a rogue's skull, clown's wrinkles. Not 
infrequently these bodily changes are traced to interference 
from outside. The patient is " cut to pieces inside," 
" vivi.sected," his soul is torn out of him, his brain is blown 
out, his heart is torn out by poison, the physicians have 
stolen his brain at an operation, and looked into his inside, 
they change his figure, his legs, his genitals, and eyes, tear" 
out his intestines. " Something else is made of my hands 
every day," said a patient. 

Ideas of Sin. — These delusions are frequently accom- 
panied by ideas of sin. The patient has by a sinful life 
destroyed his health of body and mind, he is a wicked fellow, 
the greatest sinner, has confessed unworthily, has committed 
lese-majesty, has denied God, scorned the Holy Ghost, 
neglected his gifts. The devil dwells in him, will fetch him, 
God has forsaken him, he is eternally lost, he has been 
driven out of the church, is going to hell. A patient felt " as 
if the devil wished to take hold of him." He is brought into 
relation with a murder, he is considered a spy, he is under 
police control, is watched by detectives, he must appear in 
court, must be the scapegoat for others, is to be driven to 
death. Many patients abuse and revile themselves in 
connection with such ideas. A patient expressed himself as 
follows : — 

" O you filthy beast, you are lying down again on an honoured bed — 
you are again to blame for it — there is a new waitress there again, 
nothing but princesses, whom you are bringing into confusion. If you 
only had the courage to get drunk I Insolent beast I Thunder and 
lightning shall strike in I If I had defended myself better yesterday. 
The thunderstorm shall strike in and damn you, beast — everyone's falling 
ill I 1 should long ago have been drunk ! " 

Ideas of Persecution. — In connection with these ideas of 
sin ideas of persecution are invariably developed, in the 
shaping of which hallucinations of hearing generally play an 
important part. The patient notices that he is looked at in a 
peculiar way, laughed at, scoffed at, that people are jeering at 
him, are spitting in front of him. the clergyman makes 
allusions to him in the sermon. He is grossly abused and 
threatened, his thoughts are influenced, he is surrounded by a 
" spiteful revolution." People spy on liim ; Jews, anarchists, 
spiritualists, persecute him, poison the atmosphere with 
poisonous powder, the beer with prussic acid, generate magic 
vapours and foul air, do not let him take a single good 



28 



DEMENTIA PRECOX 



breath, try to wash liim away with musk water. He must 
die, will be shot, beheaded, poisoned by the State, petroleum 
is poured over him and set on fire, he comes into the iron 
maiden, into a vault with toads and broken glass. His house 
is blown into the air. his wife is imprisoned, his brother has his 
*' flesh torn o(T." his family is shot ; the patient must drink 
the blood of his relatives. The peculiar sensations of 
influence lead to the idea that witchcraft and charms are 




Representation of bodily influences. 



being practised. The patient feels himself hypnotized by a 
magnet, bewitched, " possessed by the god IMuto," surrounded 
by spirits. " A nest of spirits lives in my brain." He has 
been taken for a telephone post, the telephone goes through 
him. 

Ideas of Influence. — From the examples which have 
already been given it can be seen that very often the 



PSYCHIC SYMPTOMS 29 

delusion of influence through external agents is developed ; 
" In a natural body such things do not happen." A patient 
sketched the picture reproduced iii Fig. 2, from which at 
least so much can be gathered that in his opinion his per- 
secutors took the most varied parts of his body as the points 
of attack for their malevolent importunity. Many patients 
are entangled in an inextricable net of the most painful 
ideas by the feeling of forced and powerless dependence on 
strange influences. The following fragment of a letter gives 
some insight into that kind of train of ideas : — 

" I am in terrible anxiety. There is the greatest danger that my life 
is coming to an end with fear, because the whole institution is arranged 
like clock-work, which is managed, not by reason, but by crazy heads in 
the cells, which are regulated like toothed wheels, and not only are the 
cells so arranged that one must move to and fro in haranguations as on 
a telegraphic cobweb of nerves, also in the passages each square yard is 
a division that demands a hanging man to appear from anywhere 
whether it is for a view or a brutal person. At the same time vapours, 
waves of heat are developed in the divisions which produce a dreadful 
degree of embarrassment on the one hand, brutal fascinating power and 
rapidity on the other ; with that there is a continuous sound of medium 
sounds, mediation voices which in a cruel manner perterrorize the mind 
with contradictions. It is quite indescribable with what wicked refinement 
these dialogues are carried on, which by the aid of influences are trans- 
ferred in destructive manner treacherously from body to body and give 
witness that so-called crazy stationary in combination with all sorts of 
drivers and haranguers are the most cruel criminals in life which there 
are, who are yet surpassed only by another class which in certain 
circumstances take hold of one and crush him with poisoned fingers in 
an unscrupulous way like a stuffed lifeless mass in another condition. . . '' 

Hxalted Ideas. — In a large number of cases ideas of 
exaltation are added to the ideas of persecution, sometimes 
from the beginning, more frequently first in the further course 
when they often come quite into the foreground of the 
clinical picture. Here and there perhaps only ideas of 
exaltation are observed. The patient is " something better," 
born to a higher place, the " glory of Israel,"' an inventor, a 
great singer, can do what he will. He is noble, of royal 
blood, an officer of dragoons, heir to the throne of Bulgaria ; 
Wilhelm Rex, the Kaiser's son, the greatest man in Germany, 
more than King or Kaiser. Or he is the chosen one, the 
prophet, influenced by the Holy Ghost, guardian angel, 
second Messiah, Saviour of the world, the little God, who dis- 
tributes grace and love, more than the Holy Ghost, the 
Almighty. He has carried on the battle of life, conquered 
death, turned the axis of the earth, can make weather, can 
walk on the waves. He lives in Berlin, gets a uniform, must 
go to the Kaiser, can become minister and pope, will be a 
good match, will get a great inheritance, gets milliards from 



30 DEMENTIA PRECOX 

God ; at the vvar-oflfice there is gold deposited for him. 
Female patients are countesses, princesses, queens ; they 
possess the whole world, have the dignity of the Mother of 
God, get gold-embroidered clothes, children from the Grand 
Duke and from the Kaiser, will marry the surgeon-major or a 
prince, their uncle has left millions. 

Sexual Ideas. — A conspicuously large place in the 
clinical picture of dementia prjecox, seems to me to be 
occupied by sexual delusions which are often connected witli 
the sexual sensations described above. The ideas of sin are not 
infrequently connected with this domain. The patient has 
committed sin with his stepdaughter, with his sister, has had 
intercourse with cows so that hybrids have been produced ; 
he has committed a crime against decency, has ruined himself 
by sexual excess, is homo-sexual, is a sadist. He has 
become impotent through onanism, the ' neurosis ' proceeds 
from onanism, onanism can be recognised in his face. A 
patient kept a record of his seminal emissions. Another 
was always obliged to think of filthiness (sexual intercourse 
with his mother); a third "could not get rid of the thought 
that his wife committed lewdness with animals in order to 
punish him for onanism." Improper thoughts always came 
to a patient against her will. Female patients notice that 
men wish to seduce them, policemen and soldiers wish to 
have them all. A dog with a muzzle on seemed to a patient 
to indicate his sexual restraint ; when his landlady brought 
him an egg for breakfast he regarded that as an invitation to 
sexual intercourse and prepared to accept it. Another patient 
felt impelled to have intercourse with his sister. 

Rut above all things patients feel themselves sexually 
influenced in the most varied ways. A neighbour's wife 
occupied herself at night with the genitals of the patient, nuns 
constantly withdraw seminal emissions from him and behave 
immodestly before him. ' Love-stories ' are given him in his 
coffee, grated flesh-flies are mixed in his food so that his penis 
becomes bine. Sexual dreams are suggested to him, proposals 
are made to him from a distance, women with butterfly wings 
come to live with him, the landlady "will force nature on 
him." He is weakened in the genitals, loses sexual power, 
something is stuck in from without, he is enticed to onanism, 
he is castrated because of self-abuse, the .students want to 
" dock " him. Women feel that they have lost their 
virtue, that their honour has been tarnished ; their father, 
their clergyman has abused them ; their master, the Kaiser 
comes at night to them. Gentlemen are sent to them for 
sexual intercourse, someone lies on them every night. They 



PSYCHIC SYMPTOMS 31 

are raped in aniESthesia, " spiritually abused," are pregnant by 
a cup of coffee, by a shadow, by the devil, by Lohengrin, have 
children in their body, must always bring forth ; things are 
said as if they were expecting to be confined and were 
committing abortion ; their womb rises into their head. The 
institution is a brothel, a house of ill-lame, in which filthiness 
is carried on. 

In connection with these insane ideas an irritable aversion 
to the other sex is not infrequently developed. A patient 
spat at the girls he met. Women fall into lively excitement 
as soon as the physician comes near, speak abusively in 
obscene language about debauchery and whoredom, will not 
have anything to do with men. A patient cut off her hair in 
order to displease her followers. 

Ideas of Reference. — The events of the outside world 
are brought into manifold connection with the delusions 
by means of "conjecturing thoughts." Indifferent remarks 
and chance looks, the whispering of other people, appear 
suspicious to the patient. " I feel myself referred to there," 
said a patient. A passer-by shows off his big nose, his red 
face on purpo.se to mock at the patient. News in the papers 
contain allusions, he finds in them thoughts which he has had. 
" My instinct tells me that," asserted a patient. His fellow- 
patients are appointed to watch him ; a patient who heard 
others speaking about him said, " I think to myself that the 
doctor gives people the commission to make me mad, the 
thunderstorm must help too." On the street he meets girls 
with whom he formerly had intercourse ; the tramway gives 
signs with the bell ; the sentries present arms. A patient 
recognised by the finger nails of his superior that he was his 
brother. People are astonishingly friendly; it is all a farce ; 
there is a change in his military pass. A patient thought it 
better to go from home when a gas pipe was going to be 
repaired in his house. Another read from the clothes of the 
physicians their thoughts about him ; a star in the sky pointed 
out his grave to a third ; the fern in his buttonhole indicated 
war to a fourth ; all labels and buttons that he found were 
important papers and pieces of money to a fifth. A patient 
held the opinion that misfortunes were brought into connec- 
tion with her menses and she would be called to account for 
it. Frequently the delusions are connected with dreams 
which are regarded simply as actual experiences or as 
significant portents. 

The delusions of our patients often show, as the given 
examples do, an extraordinary, sometimes wholly nonsensical 
stamp. As a rule also they are either not at all, or only in a very 



32 DEMENTIA PR^ECOX 

sui^erficial way, worked up mentally and are scarcely brought 
into inner connection with one another. The patients do not 
try to give any account of the reliability of their observations 
and conclusions, do not search for explanations of their 
remarkable experiences, their persecutions, their good fortune ; 
they make no difficulties and pay no regard if any are pointed 
out to them, but rather hold the more to their insane ideas 
without further proof. " I have innumerable proofs and not 
one," said a patient." 

But always here and there we meet with a certain 
systematisation of the morbid ideas mostly indeed only 
temporary ; they are connected with one another by all sorts 
of unwarranted assumptions or subtle arguments. For 
example a patient wholly out of his mind demanded as com- 
pensation for his supposed unjust detainment in the 
institution simply the civil list of the King, as he explained 
that the denial of justice, if only towards a single subject, 
. signified the virtual abdication of the King as the stronghold 
of justice ; he, the injured party, must accordingly demand 
what the King by the permission of injustice voluntarily 
resigned. 

In accordance with their generally very loose inner con- 
nection the delusions are for the most part by no means 
constant, but they change their content more or less quickly 
by the disappearance of former and the addition of new con- 
stituents. At times the patients produce nearly every day 
new delusional details in spite of certain persistently returning 
characteristic featuies, and perhaps let themselves be stimulated 
to further delusions by suggestion. In the overwhelming 
majority of cases, however, the delusions which are at 
first often very luxuriant, gradually cease. At most a few 
insane ideas are for some time adhered to without being 
further developed, or they appear once again from time to 
time, or finally they fall into oblivion permanently and 
completely. Only in that group of observations with which 
we shall later become acquainted as paranoid dementia are 
the delusional ideas generally more connected for a longer time, 
perhaps for some years, and appear unchanged in the main 
point, but here also they become gradually more confused and 
more contradictory. 

Emotion. — Very striking and profound damage occurs as 
a rule in the emotional life of our patients. The most 
important of these changes is their emotional dulness. The 
disorders of attention which have already been mentioned 
might be essentially connected with the loss of interest, the 
loss of inner sympathy, with the giving way of those 



PSYCHIC SYMPTOMS 33 

emotional main-springs which move us to exert our mental 
powers, to accomplish our tasks, to follow trains of thought. 
JHhp* «siilgula r indifferenc g^pf jy}e_p^atients tm^^ their former 
emot ional relations, the .:ejct inctio7r"or^ffection for rel atives 
ancnVfewfer'isr^satisfaction in tlieir wor k and vocatt^ g^lSr 
re*c?(eatlort and~pleamires, Is iToT seldom the^Rrst and most 
strikfrrg symptom of the onset of disease, j The patients have 
no real joy in life, " no human feelings"; to them "nothing 
matters, everything is the same "; they feel " no grief and no 
joy," " their heart is not in what they say," A patient saidTie 
was childish and without interest, as he had never been before. 
Another said that nothing gave him pleasure, he was sad and 
yet not sad. Again another stated that he had " inward peace 
in his soul "; a fourth said " I am as cold as it is possible to be." 
" Everything is frightfully indifferent to me, even if I should 
become quite insane," said a female patient. 

Hopes and wishes, cares and anxieties are silent ; the 
patient accepts without emotion dismissal from his post, 
being brought to the institution, sinking to the life of a 
vagrant, the management of his own affairs being taken from 
him ; he remains without more ado where he is put " till 
he is dismissed," begs that he may be taken care of in an 
institution, feels no humiliation, no satisfaction ; he lives one 
day at a time in a state of apathy. The background of his 
disposition is either a meaningless hilarity or a morose and 
shy irritability. One of the most _^hrirf^rferistir featur es o f 
the disease is a freque nt, causeles ^^^^ udden outburst of 
laughtet%\.\\di\. often is strikingly in evidence already at the" 
very commencement. " His thoughts always made him 
laugh," said the relatives of a patient. 

Moral sentiments also and their regulating influence on 
action suffer severe loss. \ Not only in the former history of 
the patient do we find manifold contraventions of the penal 
code and public order, but also during the disease itself deeds 
are frequently committed which are dangerous to the common 
weal./ Pighini found that among 114 mental patients who 
were sentenced, 49* i per cent, were cases of dementia praecox. 

Loss of sympathy is shown in indifference and want of 
understanding for the misfortunes of others, in the roughness 
with which the patie nts occasionally ill-use tl^!F~Lu Mr pdii'tDn s 
iTT lllibfui tune 'Uil the most tntiing occasion ; a woman tried 
to strangle the patient in the next bed in order to free her 
from her troubles. Even the fate of his nearest relatives affect 
the patient little or not at all. He receives their visits without 
a greeting or other sign of emotion, does not enquire how 
they are, takes no share in their joys or sorrows. A patient 

c 



34 DEMENTIA PR^-XOX 

remained quite indiflfereiit to the death of his mother, and 
then excused himself, as lie could not help it ; " Life is nothing 
to me and death is nothing," he said. A patient who had 
Jk^ ^ut the throats of her three children because they were 
ft /oewitched and would not be rightly brought up, did not 
' \ / show afterwards the slightest emotion ; her children were 
I / now angels and well taken care of, she explained, 
\ / Another phenomenon of emotional dementia is the 

1/ disappearance of delicacy of feeling. The patients have no 
r longer any regard for their surroundings; they do not suit 

their behaviour to the situation in which they are, they conduct 
themselves in a free and easy way, laugh on .'•erious occasions, 
are rude and impertinent towards their superiors, challenge 
them to duels, lose their deportment and personal dignity; 
they go about in untidy and dirty clothes, unwashed, 
unkempt, go with a lighted cigar into church, speak familiarly 
to strangers, decorate themselves with gay ribbons. The 
feeling of disgust and of shame is also lost. The patients 
do not preserve control of the sphincters. They pass their 
excreta under them, they ease themselves under the bed, 
in the spitoon, in their hat, in the dishes, they make little 
balls of faeces, collect their evacuations in handkerchiefs or 
cigar-boxes, smear themselves with urine, wash their hand- 
kerchief in the full chamber; they take their food with their 
fingers, they spit in their bed or in their hand, or on their 
bread, they devour beetles and worms, sip dirty bath-water, or 
empty at one draught the full spittoon. The want of a feeling 
of shame expresses itself in regardless uncovering of their 
persons, in making sexual experiences public, in obscene talk, 
in improper advances, and in shameless masturbation. 

It appears also that the patients often become less sensitive 
to bodily discomfort ; they endure uncomfortable positions, 
pricks of a needle, injuries, without thinking much about 
it; burn themselves with their cigar, hurt themselves, tear 
out .the hair from their genitals, let the glaring noonday 
sun shine in their face for hours, do not chase away the flies 
which settle on their eyelids. Often, however, food retains 
for a long time a special power of attraction. When their 
relatives visit them the patients are seen hurriedly rummaging 
through their bags and baskets for things to eat, which they 
immediately devour to the last crumb, chewing with their 
mouths full. In the terminal conditions of the illness, perfect 
indifference towards all that goes on in the neighbourhood 
is often enough one of the principal features of the clinical 
picture. 

On the foundation of the more or less strongly marked 



PSYCHIC SYMPTOMS 35 

emotional dulness, however, sudden oscillations of emotional 
equilibrimn of extraordinary violence may be developed. In 
particular, sudden outbursts of rage with or without external 
occasion are not infrequent and can lead to most serious 
deeds of violence. The patients destroy objects, smash 
windows, force open doors, deal out boxes on the ear. A 
patient stabbed a girl's arm, another killed his master, a third 
killed a companion by whom he felt himself influenced. On 
the other hand the patients may suddenly fall into the most 
unrestrained merriment with uncontrollable laughter, seldomer 
into states of intense anguish. All these emotions are dis- 
tinguished by the suddenness of their onset and disappearance 
and the often quite sudden change of mood. At the same 
time they have often no recognisable connection with the 
experiences or the ideas of the patients. Bleuler, however, 
brings forward the view that in such states it is usually a 
case of contact with the " complexes," the sensitive traumata 
of life. I have not been able to convince myself of that, but 
believe much rather that we have essentially to do with the 
loss of that permanent colouring of the background of mood 
which in normal people influences all chance oscillations of 
the emotions, equalising and checking them and which only 
then lets them appear in greater strength when an important 
occasion finds a powerful echo in our being. 

Stransky has, therefore, not without justification, said that 
it is a case in our patients less of an emotional devastation, 
than of an "ataxia of the feelings^' a loss of connection with 
other mental occurrences. I am inclined to assume that 
this confusion in the emotional life is caused essentially by 
the weakening of the higher permanent feelings, whose task 
it is on the one hand to check sudden oscillations of feeling, 
on the other hand to give to our inward states permanently 
equable tension and temperature, and so to become security 
for the agreement of our emotional relations with the outer 
world. Exactly in the terminal conditions with pronounced 
dementia one frequently observes emotional irritability with 
sudden, violent outbursts, and also excitement which appears 
without cause with more or less regular periodicity. 

The comparatively great independence on outer influences 
of the temper has as a consequence that it often remains 
for a very long time extremely uniform. Many patients 
constantly exhibit a silly cheerfulness, others always a 
lachrymose dull depression or ap ill-humoured strained 
behaviour. They are not brought out of their careless 
contentment either by unpleasant occurrences or by the blows 
of fate, nor can they be comforted, nor can their affection be 



36 DEMENTIA PRECOX 

won. But the course of the illness itself can bring about 
unexpectedly some day a sudden change in their mood. 

Here and there it may be observed that the disposition of 
the patients is exactly contrary to the actual state of affairs. 
The patients laugh while they narrate an attempt at suicide, 
or the death of a near relative, and weep bitterly on any 
occasion for mirth. Sometimes it is only a case of want of 
relationship between mood and expression — of paramimia. 
The most frequent occurrence of the kind is senseless 
laughing without mirthfulness. The patient cannot help 
laughing ; he does it even when he does not wish to ; he has 
"laughing fever," said a patient. Also the mingling of 
crying and laughing, crying in tune, dancing about with 
fixed and furrowed features belong to the paramimic 
phenomena. 

But further there sometimes takes 'place in the patients a 
complete reversal of their emotiofial relationships, which may 
be the first sign of the approaching illness. Former feelings 
of affection are changed into downright aversictn. In 
especial the nearest relatives suffer frequently. Towards his 
parents of whom he has hitherto been fond, the patient 
behaves rudely, haughtily, threateningly ; he abuses them in 
obscene language ; his mother is an old spitfire, his father is 
a rogue, a perjured dog. His mother stupefies him, is a 
witch ; his father causes him headache ; his sister is the 
devil, " the whore who has ruined his life." His brother has 
signed the deed for his execution ; his brother-in-law shoots 
him. The former lover becomes an enemy and persecutor, 
who stirs up the people and is everywhere in evidence. And 
senseless jealousy is not rare. His wife has secretly married 
another man ; the nurses wish to alienate the loved one ; 
the husband has been changed. A patient suddenly tried to 
poison her new-born child, as it seemed to her it was not the 
right one ; she asked the public prosecutor by telegraph to 
arrest her husband as he wanted to murder her. 

Like the thoughts, the feelings of the patient can also 
occasionally be " transferred " in his opinion ; " there are 
transferences of grief " ; " feelings of anguish come from 
outside by the ears, inward thoughts of persecution," said a 
patient. Another asserted that his sister had an apparatus 
for speaking at a distance, 150 to 300 miles; by the current 
one could be made to fall in love, to grieve, to have bad 
thoughts. The patient '^ has no peace at work because some 
one always sits beside him." " The laughing is made by 
voices," explained a patient ; " that is not laughing, my 
mouth is drawn askew," said another ; " the nerve of laughing 



PSYCHIC SYMPTOMS 37 

is irritated," said a third, it is an electrical laughing. " The 
laughing comes to me from beneath upwards ; it makes me 
laugh, and yet it is not laughable," said a fourth ; and a 
patient complained, " Now again another quite stupid fit of 
laughing is caused in me ! " 

Volition. — Hand in hand with the profound disorders of 
the emotional life go the extensive and varied morbid 
manifestations in the domain of work and conduct, which 
specially give the clinical picture its peculiar stamp. They 
are composed of a series of diverse fundamental disorders. 
In the first place we have commonly to do with a general 
weakening of volitional impulses. The patients have lost 
every independent inclination for work and action ; they sit 
about idle, trouble themselves about nothing, do not go to 
their work, neglect their most pressing obligations, although 
they are perhaps still capable of employing themselves 
in a reasonable way if stimulated from outside. They 
experience no tediousness, have no need to pass the time, 
'* no more joy in work," but can lie in bed unoccupied 
for days and weeks, stand about in corners, *' stare into a 
hole," watch the toes of their boots or wander aimlessly 
about. For work they have " no inclination " ; " their nerves 
can't stand it." A patient did no work for two years, "in 
order not to deprive people of gain " ; another had in view, 
after having used his last sovereign, to go into the Lake of 
Constance ; a third asked " for an easy job, perhaps as a 
clergyman." 

Automatic Obedience.-^This loss of instinct for occu- ^^.j^- 
pation, even though its clinical manifestations may be "" 
inconspicuous, represents without doubt an unusually severe X^ 
disorder, as the activity of the will forms the most important 
foundation of psychic personality. To it there stands in i 
close relationship that susceptibility of the wi ll to in^MenceA 
which finds its most distmct expression in the phenomena"©! 
automatic obedience. As the inner activity of volition fails, 
the resistance which outside influences meet within us is also 
easily lost. The patients therefore are usually docile, let 
themselves be driven as a herd, so that they form the 
necessary nucleus of those crowds which conform willingly 
to the monotonous daily round in large institutions. A not 
inconsiderable number join without resistance the crowd of 
vagabonds which chance leads to-day hither, to-morrow 
thither. 

But also fully developed automatic obedience is extremeh- 
frequent. It is found in all stages of the disease, at the 
beginning as well as at the end, not infrequently also as the 



38 



DEMENTIA PRiECOX 



one noticeable remaining feature of the disease in otherwise 
apparently complete recovery. It is seen in zvaxy flexibility, 
in the preservation of whatever positions the patient may be 
put in, even although they may be very uncomfortable. 
This very striking disorder is plainly seen in the group in 
Fig. 3, which brings together a series of patients suffering from 
dementia pr.tcox. They were put without difficulty in the 
and kept them, some with a sly laugh, 
seriousness. The patient sitting on the 
fairly demented, while the three patients 
still in the initial stages of the disease. 



peculiar positions 
others with rigid 
right was already 
on the left were 





* 






H 


m 


^^^^H .^^^^^^^^^^'~' 1 





Fig. 3. Group of schizophrenic patients. 

Further the Figures 4, 5, 6 show the same patient in different 
positions in which he was put, of which specially the last one 
could obviously be preserved only by a considerable expendi- 
ture of force. " I have to do it," said a patient, when he was 
asked about the cause of his cataleptic behaviour ; another 
said, " It happens to order." 

Again automatic obedience, as its name expresses, appears 
in involuntary obedience when called upon to do things, 
even those which are visibly disagreeble to the patient. He 
continues to put out his tongue when commanded to do so 



PSYCHIC SYMPTOMS 



39 



although one threatens to stab it, and causes him pain with 
a needle, as can be seen by the grimaces he makes. It might 
also be considered as automatic obedience that the patient 
submits to unpleasant touching of his face, tickling of the 
mucous membrane of his nose, piercing a fold of his eyelid 
without defending himself, in as far as these proceedings 




Fig. 4. Waxy flexibility (a). 

contain the unspoken command not to prevent them. Again 
ccholalia and echopraxis belong to this group of phenomena, 
the involuntary repetition of words said to them, the imitation 
of movements made in front of them, or the continuance of 
movements passively initiated. " I do it because you wish it 
so." " I place myself according to what is commanded." 



40 



DEMENTIA PR^^COX 



" I was unconscious, I had to do everything," say the patients. 
But in the end a curious constraint of the movements is 
invariably connected with automatic obedience, whicii 
apparently stands in relation to the inner want of freedom 
of the patient, with the uncertainty of the patient's own will 
and its susceptibility to influence from all possible accidental 
occurrences. Often indeed is it so distinctly marked that it 




Waxy flexibility (b). 



makes the conclusion very probable that there will be other 
disorders of automatic obedience. 

Impulsive actions — The weakening of the dominion of 
will in the psychic life provides further, as it apf>ears, the 
conditions favourable for the appearance cf the impulsive 
actions which attain such great significance in dementia 



PSYCHIC SYMPTOMS 



41 



praecox. The relaxing of those restraints, which keep the 
activity of normal people in well defined paths, provides 
chance impulses with the freedom to turn themselves un- 
hesitatingly into action without regard to the end in view or 
to suitability. So it happens that the patients commit a 
great many of the most nonsensical and incomprehensible 
acts of which they themselves are usually unable to explain 




Fig. 6. Waxy flexibility (r). 

the cause. " I have a sort of feeling as if I must do that," 
explained a patient who was screaming and biting everything. 
■" I had no free course left me, I had often to do things 
without knowing why," said another. A third said, 'I must 
shuffle and do gymnastics," a fourth, " I must scream in 
order not to burst " ; a fifth sang, " because it was desired " ; 



42 DEMENTIA PRECOX 

a sixth asserted that " God made him spit." The patients 
suddenly break a mirror in pieces, knock over tables and 
chairs, take down pictures, throw objects out at the window, 
climb on to a cupboard, set fire to their hair, run naked into 
the street, ring bells, put their heads in the basin of the 
water-closet, set the chamber on their head, creep under the 
table, smash a lamp. Usually such senseless actions are 
carried out with great violence, suddenly, and with lightning 
rapidity, so that it is impossible to prevent them ; the patients 
also oppose themselves in the most insolent way to every 
attempt to keep them from doing these things. " I had a 
feeling as though I were not doing my duty ; there was an 
impulse in me," were the terms in which a patient described 
his inner perceptions. Another smashed the fire-alarm, 
" because he had the impulse in his arm"; a third, who with 
all his might was struggling and drumming called out, " I 
cannot do it any more vigorously ! Am I to do it still more 
vigorously? " 

In certain circumstances the impulsive actions of the 
patients may become extraordinarily dangerous. The 
patients suddenly give a box on the ear to any one they 
meet, make a furious attack on a neighbour, set fire to beds, 
tear off a gas-bracket. A patient tried to throttle his uncle's 
grandchild ; another smashed the bell at a level-crossing and 
wanted to tear up the rails as well ; he alleged as his motive 
that he had been shut up in Roumania and made insane. 
Others bite their arm, strike their face, squeeze their testicles 
together, drink up any bottle of medicine, put beetles or 
stones in their ears, make continuous attempts at suicide, 
suddenly hang themselves, jump out at the window, throw 
themselves in front of the tramway ; a patient broke a tea- 
spoon in order to stick it into his neck. 

Often sexual impulses are also very lively. The patients 
masturbate without regard for their surroundings, or in the 
examination by the physician, snatch at the genitals of their 
fellow-patients, take hold of their sister under her skirts. A 
patient raped his brother's cook and tried to do the same to 
his sister-in-law. A female patient for years made regardless 
sexual attacks, on the physicians, in order through inter- 
course " to be freed from the oppression on her breast." 

Catatonic Excitement. — The peculiar condition of 
catatonic excitement consists of a collection of .senseless 
actions and movements with which we shall have later to 
occupy ourselves more in detail. Besides impulsive actions 
we meet at the same time in large number and variety with 
discharges of will-power, in which every relation to the 



PSYCHIC SYMPTOMS 43 

realisation of fixed aims is wanting, but which appear in the 
form of completely aimless movements. They have no 
connection either among each other or with ideas or 
emotions, but have the tendency to repeat themselves very 
often either in the same form or with all manner of changes. 
Here and there they still bear the character of mutilated 
movements of purpose or expression, from which partly at 
least they may arise. The patients hop, jump, turn somer- 
saults, scream, grunt, see-saw, drum, screech, go through the 
movements of ringing, of playing the violin, usually with the 
expenditure of all their energy, but without any recognisable 
aim. 

Stereotypy. — With the disorders of volition which have 
already been considered, there is very frequently connected 
in dementia pra^cox, as has already been indicated, another, 
the tendency to the instinctive persistence of the same 
volitional movements, stereotypy. It shows itself in con- 
tinuance in the same positions as well as in the repetition of 
the same movements or actions. The will is here to a certain 
extent influenced for a considerable time by previous activities, 
in the same way as in automatic obedience. Stransky there- 
fore speaks, probably with right, of an " auto-echolalia '^ and 
" auto-echopraxis." The patients stand or kneel for hours, 
days, or still longer, on the same spot, lie in the most un- 
comfortable positions in bed, fold their hands spasmodically, 
even till pressure-sores appear, take up the position of 
fencing. Usually it is possible only with the most extreme 
force to bring them out of such a position, which they 
usually take up again as soon as the hindrance has ceased. 

Much more varied are the stereotypies of movement 
which we often meet in the most marked form, especially in 
states of catatonic excitement. In the milder degrees it is 
more a matter of a certain uniformity of volitional expression, 
the persistence of definite activities. The patients always 
make the same gestures, go the same ways, pull their hair out 
like the patient represented in Fig. 7 ; they make bread 
pellets, continually scratch their faces, slide dovyn on their 
knees, make peculiar noises, make grimaces, play all day long, 
the same tune on the piano ; a patient " threw his roll on to 
the table a hundred times." In the same category there 
belong also twitching movements in different groups of 
muscles, raising a shoulder, " contortionist movements," 
waving with the hands, touching definite parts of their bodies 
with their fingers, conspicuous clearing of their throats, 
smacking of their lips, snorting. A patient who always 
twitched with his alae nasi, explained, " That is just my way." 



44 



DEMENTIA PR/ECOX 



Sometimes the whole volitional expression of the patient 
is dominated by stereotypies for a long time, so that his 
doings resolve themselves into an almost uninterrupted series 
of senseless movements which are either monotonous, or 
repeat themselves with slight changes. A certain rhythm 
invariably results. The patients rock themselves from one 
leg on to the other, keep time, "pull letters away from their 
fingertips," spread out their fingers with a quavering move- 
ment, clap their hands, shake their heads, bellow keeping 
time, give themselves boxes on their ears, run up and down 




Fig 7. I lair-pulling puticiU. 

in double quick time. About the motives for these 
proceedings, no satisfactorx- account is got from them. A 
patient who always rocked himself rhythmically from side to 
side, simply e.xplained, " It happens so in me," " T must 
shake my head or else I am in terror," " I must constantly 
say things," " I must .scream without wanting to, there is 
that impulse in me," " I must throw myself about at night in 
bed as if a strange power threw me," " I must turn round, 
as when a magnet draws a needle," " I could not have rested 
till I had done that," are similar expression.s. 



PSYCHIC SYMPTOMS 45 

We may well suppose that also the development of such 
stereotypies, which later give such a peculiar appearance to 
the terminal states of the disease and likewise to many forms 
of idiocy, is specially favoured by the failure of healthy 
volitional impulses, perhaps first made possible. Many 
experiences at least indicate that the mechanism of our will 
possesses arrangements acquired long ago, which favour a 
rhythmical repetition of the same discharges ; their influence 
will be able to make itself felt as soon as the impulses dis- 
appear which serve for a realisation of intentions. 

Mannerisms. The uncertainty and weakness of the 
volitional movements which are accompanied with conscious- 
ness of purpose, and further the ease with which all possible 
impulses can influence volitional expression perhaps explain 
how it is that the actions of our patients often end in 
morbidly changed forms. Even simple movements can show 
such changes. Sometimes they are carried out with too 
great an expenditure of force, or unnecessary groups of 
muscles take part in them, or too much of the limb is 
employed, so that they become ungraceful and clumsy ; or 
they are not rounded off, they begin and end jerkily and 
appear therefore stiff, wooden, and angular. Other patients 
again arrive at the aim of the movement not by the nearest 
way, but by round-about ways with all sorts of changes 
and interpolations ; they add flourishes by which the move- 
ments become unnatural, affected and manneristic. Through 
such peculiarities, which are called mannerisms, the processes 
of breathing, speaking and writing, standing and walking, 
dressing and undressing, shaking hands and eating, smoking, 
gestures, and the mode of setting to work, can be influenced 
and transformed in the most manifold way. Grasping is 
done with fingers spread out ; speaking is accompanied with 
loud hawking and grunting or with smacking movements of 
the lips, the face is distorted by spasmodic grinning ; among 
masons every stone is first turned round several times before 
it is laid in position. Many patients lift their legs in walking 
" like the stork in the lettuce " ; a male patient promenaded 
about with his shirt solemnly lifted ; a female patient played 
the piano with gloves on. 

The process of taking food especially may be changed by 
the most manifold side impulses. Frequently the patients 
simply thrust their hands into their plate, fall upon the 
common dish, hurriedly stuff their mouths as full as possible 
and swallow their food down almost without chewing, or 
the spoon is grasped quite lightly with their finger-tips, often 
at the extreme end and the handle is used for eating; their 



46 DEMENTIA PR/ECOX 

food is invariably stirred about with their forks two or three 
times before each mouthful, the vegetables are divided into a 
row of equal little heaps, their hands are first wrapped up in 
their coats, their nose is stuck into the soup, or there must be 
a mouthful drunk between each two mouthfuls of food till 
twelve are counted and so on. Others lap the soup like a 
dog or pour it with profuse spilling into their mouth without 
more ado, press the vegetable dish flat on to their face and 
steadily lick it clean. One of my patients took hold of the 
spoon quite correctly with the right hand, but brought it 
round her head by the left side to her mouth ; another crept 
under the bed cover at meals. 

Not infrequently the aim of the action is wholly or at 
least partially frustrated by the changes and made unrecog- 
nisable, so that the impression arises of oddness and sense- 
lessness. To this group belong such peculiarities as giving 
tlie edge of the hand or the fingertips in shaking hands, 
lying crosswise in bed, speaking with closed teeth. 
A patient covered himself with paper; another sucked 
passionately at the corner of the bed, a third dipped the 
corners of his pillow into his coffee. All these mannerisms 
have a pronounced tendency to persist, and they may form 
part of the behaviour of a patient without change for decades. 
Through them especially arise the half-repulsive, half- 
ludicrous impressions which strike the laity on visiting an 
institution for the insane, and it is those therefore above all from 
which the popular picture of " lunatic " is usually composed. 

It is made still more complete by the oddities in the 
outer adornment of the patients, the extraordinary modes 
of dressing the hair, the earrings made of pieces of wire, the 
gay ribbons in the hair and in the button-hole, the peculiar 
ornaments of the clothes. A patient drew his socks over his 
trousers ; another wore them folded together on his head ; a 
third adorned himself with bracelets of paper. Frequently 
also the patients adopt very peculiar attitudes and deportment, 
balance themselves on one leg, put their head between their 
legs, lie on the edge of the bed, spread out their arms in 
cruciform attitude, twist themselves together in the most 
remarkable manner. A patient answered as follows to the 
question why he did such things: — 

"The feeling is called forth by influence from the outer world. It is 
then as if with certain degrees of unity of the small parts with no 
reasonable handling by oneself small parts of the body (at the finger 
and other limbs) were pulled away from the entire whole with unspeakable 
pains. If I feel anywhere in my body much discomfort, which it with 
Its whole mental ability must endeavour to put right, in order not to will 
to produce these extraordinary pains, I must change my position in all 
the small parts." 



PSYCHIC SYMPTOMS " 47 

Parabulia. — Gradual transitions from the simple changes 
of ever)'-day purposeful actions lead .to those disorders of 
volition which we may gather together under the name of 
parabulia. The side impulses which at first bring about only 
flourishes in action may gradually become cross impulses 
which lead to complete derailment of volition. Some 
examples belonging to this class we have already brought 
forward in which to a certain extent a distorted picture of 
natural actions arises by the employment of unsuitable 
means. But further, an actio;i at first perhaps correctly 
begun is turned away in quite another direction by cross, 
impulses or perhaps simply stopped before completion 
(Ergodialeipsis according to Moravsik). The hand that will 
stretch out and take hold of the spoon, goes to the nose to 
scratch there; the patient who will put on his coat, puts his 
legs into the sleeves. In shaking hands the movement comes 
to a standstill halfway; the patient breaks off in the middle 
of a sentence ; he stirs his food about keeping time as he does 
so, without bringing the fork with food on it to his mouth. 

Whether we have here to do with the turning away of 
actions in a different direction or with the stopping before 
completion of actions already begun, the cross or contrary 
impulse can further suppress the volitional movement itself 
even as it is already coming into being, so that the action 
which is about to be done is not even begun, but from the 
outset is replaced by another or simply suppressed. The 
patient who is to show his tongue, opens his eyes wide 
instead, he flings the cup away instead of putting it to his 
mouth. We shall consider these " parergasias " more in 
detail in the discussion of the movements of expression. 

Negativism. — By far the most important form of para- 
bulia is the suppression of volitional movements by contrary 
impulses, negativism. It is natural that of the innumerable 
side impulses which in themselves are possible, those should 
take up a special position which are exactly contrary to the 
attainment of the end in view ; on the appearance of a 
volitional intention they are at the same time most strongly 
stimulated in consciousness by the action of contrast. 
Negativistic obstruction of volition plays therefore an 
extraordinarily large role in the clinical picture of dementia 
praecox. To begin with it leads to the instinctive suppression 
of all reaction to external influences, further to stubborn 
opposition to interference of all sorts, and in the end to the 
performance of actions which are exactly opposed to those 
which are suggested by the circumstances or required by the 
environment. 



48 DEMENTIA PRECOX 

It is,, however, certain that the disorders commonly- 
collected under the term negativism have not all the same 
origin, as Bleuler ^ in particular has shown in detail. At first 
insane ideas or ill-temper, especially anxiety or irritability^ 
cause the patients to shut themselves up from their environ- 
ment. They do not touch their food because they think it 
is poisoned, do not lie down in bed because they imagine 
that they are threatened with the danger of syphilitic infection 
there, d^o not shake hands because they distrust the physician, 
or fear his influencing them,.and they will not have anything 
to do with , him. In a similar way probably one should 
regard the resistant attitude of the bewildered and confused 
patients to whom everything appears changed, incom- 
prehensible, and mysterious ; here also anxious distrust may 
be as-umed as the mainspring of their opposition. In none 
of these cases is it a question of negativism in the sense of a 
disorder specially peculiar to dementia pr?ecox. It appears 
to me also that the behaviour of such patients towards the 
stimuli which they encounter does not differ from that of 
other anxious or irritable persons ; in especial on stronger 
provocation they fall into excitement, make lively movements 
of defence, or even pass over to attack. 

Various experiences meantime indicate that there is 
another form of resistance to outside influences, which comes 
into existence wholly by impulse that is without foundation 
on ideas or emotions. Imperative negativism, the carrying 
out of action exactly contrary to that wished, scarcely allows 
of any other interpretation. Only exceptionally could there 
be any palpable motive in the question, as when a patient 
forces his way out on being told to stay where he is. But 
when a patient begins to sing as soon as he is asked to be 
quiet, when he goes backward on being ordered to march, 
it is difficult to find an explanation in deliberation or 
emotional influences. To this it may be added that the 
patients in many cases of marked negativism actually exhibit 
neither delusions nor emotions, which could in any way 
justify their peculiar behaviour. But finally for this question 
the utterances of the patients themselves are very important 
which are almost always to the effect that they felt them- 
selves forced without being able to explain the reasons to 
themselves. " I must often do the opposite of what I am 
asked," said a patient, " I do not will as the people will," 
explained another. Certainly here and there delusions or 
hallucinations are mentioned as causes of the negativistic 
behaviour. The patients feel themselves under a " ban," eat 

'Bleuler, Psychiatrisch-Ncurol. Wochenschr. xii., i8. 



PSYCHIC SYMPTOMS 49 

nothing for a day " because God does not wish them to," 
" must not speak," " remain lying," " on a higher command," 
"because the mediums wish it," "the voices command it." 
It may, however, rightly be assumed that such reasons are 
nothing else than formulas for the characterisation of hin- 
drances to volition which are inexplicable to the patient ; 
the voices also might in this respect only give expression to 
what the patient feels in himself 

Still more distinct does the peculiarity of this disorder 
become by the fact specially emphasised by Bleuler of 
" inner negativism." As already mentioned above, obstacles 
place themselves in the way not only of external commands, 
but also of the internal volitional impulses, obstacles which 
lead sometimes only to the omission of the intended action, 
but also to the performance of a contrary one or even of an 
action of a totally different kind. " I never arrive at what I 
want to do," said a patient, " I cannot do what I wish," " I 
had no free will," " I had to do something without myself 
wishing to, sometimes to go backwards," " I had to do what 
was repugnant to my character,"" Reason fights against the 
external influence," others explain. Also " intellectual 
negativism," which has already been discussed, the appear- 
ance of negativistic hindrances in the train of thought, can 
scarcely be otherwise explained than by immediate disorders 
of that inner activity of volition which regulates the rising 
into consciousness and the connection of ideas. 

Autism. — The clinical phenomena, in which negativism 
shows itself, are extremely varied. It is a common experience 
that the patients with dementia praecox are more or less 
inaccessible, that they shut themselves off from the outer 
world. Bleuler has described this important symptom as 
autisni. The refusal of all psychic contact is often shown in 
the whole behaviour of the patients as soon as one begins to 
occupy oneself with them. They do not look up when 
spoken to, perhaps turn away their head, or turn their back 
directly to the questioner. The hand offered in greeting is 
refused, " It is not proper," " In bed the hand is not given," 
" Only women greet each other that way," say the patients ; 
they have given the hand too often formerly. Many patients 
close their eyes, cover their faces with their hands, cover 
themselves up, draw the bedcover over their head, and con- 
vulsively hold it fast ; " This position is pleasant for the 
eyes and more restful for the inner life," explained a patient. 
Often the patients refuse all information ; " That is their own 
affair," " That is no one's business," " People are cross- 
questioned in that way," "They should not be there, did not 

D 



50 DEMENTIA PR/ECOX 

require to give explanations." A patient first asked the 
physician to show him his diplomas that he might know 
with whom he had to do. Others give perverted or quite 
insufficient answers. 

Stupor. — Hut even when they do express themselves, one 
notices very distinctly by their niggardly, resisting, forced 
statements which tell nothing, the resistance which they 
oppose to any searching into their inner life. Frequently the 
patients have already shut themselves off from their family 
and their surroundings long before the appearance of the 
more striking symptoms, say only the most necessary things, 
do not appear any more at the common meals, avoid all 
friendly intercourse, bolt themselves in, take lonely walks. 
They bluntly refuse visits from the physician and friendly 
relations with their fellow-patients. As the disorder becomes 
further elaborated there is developed the picture of negati- 
vistic stupor, the rigid, impenetrable shutting up of themselves 
from all outer influences, which is connected with a suppression 
driven to the limit of the possible of all natural emotions. We 
shall later have to describe the clinical picture in detail. 

Causation of Negativism. — As has already been indicated 
in the general part, the understanding of negativism in the 
sense here depicted requires to be connected with the fact 

that our t hinking and Q.cting con st antly have to make 

decisi onS-^^ Between di flereiit^ often contrary, ideas and 
volitioijal_ resolves. ? 1 n~'esp?ecial ""ou?" whole-retationslTip^ to 
the environ metiTis governed throughout by volitional move- 
ments of inclination and disinclination, and the suitable 
choice of these possesses fundamental importance for our 
existence.^ lileuler speaks of an "ambivalence" and an 
" ambitenciency " of psychical processes, in the .sense that 
they are accompanied at the same time, by contrary emotional 
stresses and can lead to contrary emotional movements. / He 
assumes on the basis of his experiences that this discord in 
feelings and impulses comes under observation specially 
frequently and strongly in dementia pra^cox, and forms an 
important foundation for the development of negativism. ^ 

But of course even if that discord be granted, still 
further explanations are needed, not indeed why the choice 
between resistance and yielding oscillates in an unaccount- 
able wa)' which certainly often enough happens, but why so 
frequently during a long period the negativistic movements 
govern tlie sum total of the actions in so decided a way. 
So far as morbid moods or delusions play a part, I believe, 
as has been mentioned alx>ve, that it is not a case of genuine 
negativism. At most it might be admitted that with their 



PSYCHIC SYMPTOMS 51 

help the tendency to the appearance of ne<,'ativistic 
phenonnena which is present in any case, may be strengthened, 
as conversely negativism perhaps also exercises some 
influence on the content of hallucinations and delusions, as 
on the tone of the mood. 

In the last place, however, there must be other causes 
which determine the governing position of the contrary 
impulses, because of their instinctive origin and the ir 
independence of the remaining contents o f conscjousness. 
^ Besides erotic emotions which are usually even in healtTiy 
life already accompanied by discordant processes of 
emotion and volition, Bleuler regards as such, principally 
the " autistic " tendency of the patients to withdraw them- 
selves into themselves, the existence of specially sensitive 
" life traumata," and the " forcing of thoughts," the deficient 
command over the train of thought. He reckons, however, 
for the explanation of " inner negativism " also with influences 
unknown as yet. 

The significance of erotic emotions is in my opinion to 
be judged of in a similar way to those other feelings and 
therefore to be left out of account in the fundamental 
explanation of genuine negativism. That in the behaviour 
of the patients " life traumata " play a part to any great 
extent, so that they shut themselves up from their surroundings 
as a protection from contact has, as I believe, till now neither ^^ 
been proved nor even made probable ; Valso the fa ct that C ^~^ 
negativism frequently appears and disappears so suddenly; ) """^^ 
■/''■Sgginri^ to-me'To alrgue very much against such an interpretation. \ 
In contrast the "autism" of the patients stands certatiTTy t 
without doubt in near relation to their negativism, only I 
should think that it represents not so much a cause but much 
rather a manifestation of negativism. The tendency to shut 
themselves off" from their surroundings is frequently found 
in our patients already many years before the real onset of 
the disease and it is a very common phenomenon in the 
terminal states. But I very much doubt if it, as Bleuler 
thinks, is caused by the withdrawal of the patient to his 
own phantasies, and if he on this account feels every diverting 
of attention as an intolerable disturbance. Stubborn inac- 
cessibility is often enough shown by patients on tTTe~^ne 
Iraiid, in whom there can be no thought of special imaginings 
in which they could lose themselves, and it is lacking on the 
other hand in innumerable other delusional forms of disease, 
as specially in paralysis in which the patients certaintly do 
dream themselves into a world of imaginings which are 
greatly disturbed by the influences of the surroundings. 



52 DEMENTIA PR.^COX 

Vlt seems far more probable to me that negativism 
and " autism " which is only its forerunner, are not at all 
connected with ideas or "complexes," but with the general 
^ constraint^ of volitio n which is so specially peculiar to 
i, dementia pr.-ecox. \ Already on the most varied occasions 
we have had to pomt to the fact that the patients lose the 
mastery over volitio n and often feel this profound disorder 
more or less distinctly. They are heard describing their 
inner constraint always in new and ernphatic__expi:sssions. 
Their will has been taken from them ; it is weak, they have 
no will of their own any more, are not masters over it ; there 
is no independence in them. " I am not melancholy, and 
not .senseless." said a patient, " I only lack a will of my own, 
an impulse of my own." The patients feel themselves not 
free, influenced, dominated by external will, by invisible 
might, by magic powers possessed b)' superhuman beings 
"like an automaton" ; they suffer from " auto-su£f gp«itjnn ap^ 
high grade suggestibility. " stand " as under c ompulsioi i," are 
in " ^slavery to suggestion " ; "I am a^milll nildfcr cominllsion," 
explained a patient.^ An external force has power over 
them under whose ban they must wholly exist and act ; 
they must do what others wish, other people have power 
over them ; " Another person works in me ; who that is, I 
do not know," .said a patient. Another complained, " For 
a year I have no longer had any will of my own, I am 
dependent on other people ; my will becomes weaker from 
day to day ; it is a dreadful bungling of work ; 1 have no power 
to begin another life." A servant girl said she got orders as 
if she were in a situation, she was already accustomed to it. 

Sometimes the influence on volition is referred to certain 
sources. God leads the patient ; the patient is wholly under 
the influence of a companion ; he " must do what his 
brother-in-law suggests to him by thought-transference by 
electrical means." A female patient felt herself ruled " by 
a gentleman and a lady," another by her fianc^ who used 
enchantments and mystic measures in order to fetter her ; 
still another noticed that a gentleman who passed had 
power over her. A patient thought that people were sent 
to him, who were to study suggestions, and they gradually 
went over to hypnosis ; experiments were being tried on 
him; another saw an "eye like a half-moon, and had to 
follow it, he had sworn to." One of my patients, who 
thought he was put on trial by the authorities, asked them in 
thought often and urgently now at last to make an end of it ; 
he crossed the French frontier in order to see if there also 
the suggestions took place. When he had convinced himself 



PSYCHIC SYMPTOMS 53 

that the currents went over the frontier, probably by railways 
and telegraphs, he had only the one wish left, to cross the sea 
in order to take his life in case the action at a distance could 
be carried over also by cable. 

We have already mentioned that even the isolated 
peculiar acts are caused as a rule without further motive by 
irresistible impulses. The patient " must " lie down, " assume 
a strange appearance," " spit on the physician," " assume 
attitudes," walk till he can "walk no longer," "by order" run 
from one place to another, imitate everything, laugh, "even 
^hen he is sad " ; he " can do nothing against it, he must 
scratch his face ; " that is caused." A female patient 
complained there was something wanting in her head ; her 
understanding was weak ; she therefore " talked stupidly, 
was really insane, had to do such things from want of 
sense." Here and there the impulses take on the form of 
auditory hallucinations without the nature of the process being 
thereby essentially altered ; voices summon the patient to do 
this or that, and he " must do all that they ask." 

Personality. — From these and similar utterances of the 
patients it clearly follows that their thinking, feeling, and 
acting have lost the unity and especially that permanent 
inner dependence on the essence of the psychic personality, 
which provides the healthy human being with the feeling of 
inner freedom ; " I can't get hold of my will," said a patient. 
We may assume that this profound change in the psychic 
life, which indicates a complete destruction of the personality, 
must in itself influence the attitude towards the outer world 
in the most decisive way. The most natural protective 
measure of the weak consists in shutting himself up and 
hiding. The more or less distinct feeling of inner constraint 
and powerlessness which accompanies our patients along with 
childish susceptibility to influence, could therefore on the 
otheV hand play an essential part in the development of their 
obstinate seclusion.! If the disorder of volition can influence 
the conduct of the patients in both directions and if it at the 
same time makes it more difficult for them to hold fast to a 
uniform attitude towards their surroundings, we should also 
have come nearer to the understanding of the frequent 
oscillations between heightened sensitiveness to influence and 
stubborn negativism. / It is self-evident here that we must 
not, as has already 'been pointed out, think of consci ous 
delib eration. Much rather is it the general change of the 
personality and its behaviour towards the ordinary events of 
life that come into consideration as it is conditioned by the 
perception of its own inner want of independence. If one 



54 



DEMENTIA PR/ECOX 



wishes, one may with more right in my judgment regard the 
feeling of the destruction of the ivili which may precede the 
real onset of the disease under certain circumstances certainly 
by many \ears, as a " life trauma " which cannot endure any 
contact and therefore causes the patient to shut himself up. 
rather than the influence of other chance events of life. That 




Fig. S. A handkerchief embroidered with silk. 

disorder would also to a certain extent explain the tendency 
of many of the patients to spin themselves round with 
imaginings ; he who is not able to control his own will and 
with it his life, gladl)- takes refuge in the realm of dreams. 

Practical Efficiency. — As the mental, so also the practical 
efficiency of the patients is invariably greatly encroached on 



PSYCHIC SYMPTOMS 



55 



by the disorders of volition. They come to a standstill at 
every difficulty, must always be driven on again, work 
extremely unequally, do a great deal of their work wrongly, 
are completely unreliable, spoil material and tools. At the 
same time, however, a certain technical skill can be preserved. 
In their handiwork the loss of taste often makes itself felt in 
their choice of extraordinary combinations of colour and 
peculiar forms. The accompanying figure gives an example 
of the singular works of art of the 
patients ; it represents a handkerchief 
embroidered with thick silk. I also 
reproduce in Fig. 9 a stocking which 
was knitted by a patient who had had 
catatonic stupor for years. The measure 
placed beside it is 20 cm. The patient 
knitted for a number of days simply a 
long pipe, and then when she was told 
brought the stocking at last to an end. 
She next added the two remarkable 
loops and further the point. At the 
same time the work was without fault 
in detail. Many patients produce very 
queer handiwork, a glove made of 
human hair, linen coverings for horses' 
hoofs, dolls made of cotton wool. The 
musical performances of the patients 
also show distinctly the decline of fine 
artistic feeling as they play sometimes 
without expression, sometimes in an 
arbitrarily incorrect way. After the 
more stormy manifestations have run 
their course, it is often possible to 
educate the patients again to simple 
work which they then accomplish with- 
out circumspection or self-reliance, and 
often with all sorts of caprices, but still 
with the regularity of a machine. A 
few patients continue work without 
showing any sign of fatigue or annoy- 
ance, till they are told to stop. 

Self-expression. — The general disorders of volition often 
take many peculiar forms in the movements of expression of 
the patients.^ The cessation of the need to express oneself 
corresponds to tKe disappearance of volitional activity. The 

^ Mignot, Annales medico-psychol, 1907, II. i. Morawsik, Allgem. Zeitschr. 
Psychiatric, 1907, 733. 




1 ig- 9- 
Singular stocking (Catatonia). 



56 DEMENTIA PR.'ECOX 

patients become monosyllabic, sparing of their words, speak 
hesitatingly, suddenly become mute, never relate anything on 
their own initiative, let all answers be laboriously pressed out 
of them. They enter into no relations with other people, 
never begin a conversation with anyone, ask no questions, 
make no complaints, give their relatives no news. They 
write no letters or only those with almost nothing in them, 
stop after writing a few lines. Their facial expression also is 
vacant and dull ; their gestures are limp, few, and monotonous. 
On this foundation echol^lia ea silyap pears. which makes 
itself known in the involuntary repetition of questions asked 
or other things said to them, as well as in the introduction of 
fragments of speech caught up into their own utterances. 

In the states of excitement in place of taciturnity a pro- 
digiou ^ _ /fgtc^ of talk may appear which does not correspond 
to a nee d for e xpress ion, but usually unburdens itself without 
anx ieferenceTo the surrounding s. Often it consists of out- 
^ur.sts of filthy abuse, piercmg shriek s or singing ; a patient 
whistled tunes all day on a water-bottle ; many patients 
carry on monologues or answer voices loud out, often cursing 
and abusing, especially in the night. The following is a 
record of a fairly lively dialogue of this kind, which a patient 
carried on with his voices : — 

"What does it matter to me tlien what you think ! That has nothing 
to do with me, is in the highest degree indifferent to me. — What? I 
must think that? That I must not at all. I can think what I like, and 
you think what you like I — That would be still better? No, that would 
not be better at all I I can certainly do with my head what I will I I 
must wholly misunderstand you I That is entirely your affair if you 
share your thoughts with me ! It is not I who am ill. -You are the 
patient I I am a real, sensible person, and the superintendent is carrying 
on the most infamous game, is carrying on criminal fabrication ! — What? 
Am I to shoot myself? I don't think so I Shoot yourself if you like I 
I am not going to do you this pleasure I — What? I am stupid? No 
you are stupid ; I am cleverer than you all ! I am too clever for you ; 
that's why you want to keep me in here — It doesn't helj) me at all? 
We'll see that, if it doesn't help I There is still a Bavarian State with 
guaranteed rights, and you will be put in jail I As far as I'm concerned 
lick me I " 

Incoherence of the train of thought, as we have 
already depicted it, is usually distinctly noticeable in the 
conversation of the patients. The most different ideas 
follow one another with most bewildering want of connection, 
even when the patients are quite quiet. A patient said " Life 
is a dessert-spoon," another, " We are already standing in the 
spiral under a hammer," a third, " Death will be awakened 
by the golden dagger." a fourth, "The consecrated discourse 
cannot be over split in any movement," a patient, " I don't 



PSYCHIC SYMPTOMS 



57 



know what I am to do here, it must be the aim, that means 
to steal with the gentlemen." 

The page, which is reproduced as a specimen of writing 










X 7^^f^- 







^l^^l^l^T*' ^^y - »^.»f-»y^ 







Specimen of writing i. Incoherence. 

No. I with notes of a patient, as he used to produce them 
in large number, gives a good impression of this incoherence. 
The arrangement of the notes, the handwriting changing in 



58 



DEMENTIA TR/ECOX 



size and form, the irregular grouping, the underlining of 
different kinds and colours make it appear peculiar and 
incomprehensible. In detail we have a varied mixture of 
broken words and fragments of sentences before us, among 
which there is no connection whatsoever. We only notice 
the recurrence of single parts (" Bau," " baum," " Hauptbau/ 
" Charakter," " Wortschatzbuch," " Wort-stiel-baum," " Geist- 
Stoff," "Haft," " wahrhaftigste," "fort"). The affected use 
of hyphens is further noticeable (" Bau-m," "Grama-tik," 



''•**^, 




-^*«--^<4^ 1 -n \> >> f////?f^ 




Specimen of writing 2. Incoherence wiili Stereotypy. 

" Or-tho-graphie ") and of marks of exclamation (" ! ! Weide ! !," 
" ! ! Werde : ! "), and the writing above the line of the last 
letters in numerous words, and lastly among the other notes 
the curiously encouraging remark " (sig-ste-was??)," and 
"grundfalsch " written with a flourish across it. 

Still more incoherent is the above piece of writing. 
(Specimen of writing 2.) Here there are certainly still .some 
connected words decipherable ("the day's no longer far off 
and the night greets us again," " salutation and blessing 



PSYCHIC SYMPTOMS 



59 



from the apostolic over"), but intermixed there are irregularly 
strewn incomprehensible aggregations of letters, childish 
drawings, single signs like letters and numbers, a group of 
similar strokes, which let the tendency to persistence of 
the movements of writing appear clearly, as do also 
the words that return in various forms, "Juden," " Gus- 
Gruss-Grund," " Hohen-Hoch-Hohre." The extraordinary 
irregularity of the hand-writing should also be noticed here. 

In the drawings of the patients also there invariably 
appears on the one hand incoherence, on the other hand 
persistence of impulse to movement. Fig. lo reproduces 
one of the senseless, childish drawings which a patient 







Fig. lo. Drawings in Dementia Priecox (Metamorphoses). 

produced in large numbers daily ; there are wonderful 
combinations of strokes and flourishes with hints of stereo- 
typy. They correspond completely with what Pfersdorfif 
has named metamorphoses ; there were endless variations 
of the same recurring fundamental form. 

The second example, Fig. ii, gives the impression at the 
first glance of a pen and ink drawing. It is composed, 
however, of senseless combinations of strokes. Besides these 
there are notes with written verbigeration, enumerations and 
plays on words (" Irre-Irrengarten - Irrenspaziergange, 
Irrenreichman " and so on, " Irrenwurz, Eierwurz," " Abtritt- 
Pissoir, Latrine-Scheisskerle," "Lukretia, Metardus,Onophrius, 
Primus-Benignus "). Such expressions of quite divergent 
stamp are interpolated in the most elegant and regular hand- 



6o 



DKMKXTIA PR/KCOX 



writing. The third example also (Fig. 12) shows besides the 
startHng senselessness antl tastelessness of the design, the 
monotonous recurrence of the same details, and lastly the 
incoherent inscriptions in which " Scmiramus," " Jeremias," 
" Apollo" are joined with*' Ludowicum Napoleon," " Markus," 
*' Chamisso " and " Woltaires." 









■ aUf^u'::-'- ^ *^' ^ Jry< ^-f >^ 



f. 


















r 









'I'J^'^^^v;^ '. 




I'ig. II. Senseless Drawing. 

Similarity in Sound can be recognised here and there as 
a certain link in the disconnected utterances of the patients. 
They rhyme, " Ott Gott," "simbra-umbra " ; they play sense- 
lessly with words and sounds. A patient spoke of " Khebrechcr 
and Heinbrecher," another of " verhort und verstort," a third of 
" Sauspiel and Schauspiel." A fourth explained his spitting 




. v.: \ 




Fig. 12. Queer Drawing. 



62 DEMENTIA PR/ECOX 

with 'Zurtuss, Eiiifluss, and Ausfluss"; a fifth said "jet/.t 
miissen Sie mich herunteifragcn.damit es wieder heruntergeht." 
a sixth, " Ich bin der Hesitzer und Ihr seid die Schwitzer " ; 
a seventh wished " Vorrichten statt Nachrichten " ; an eighth 
called himself " Gottes Sohn und Gottes Schwur" ; a patient 
spoke of Albicocca, Kokken, Kokain. 

How the train of thought may be interrupted by meaning- 
less plays on words is shown b\' the following passage which 
was written by a young patient who amused himself a great 
deal with writing : — 

"d.i droben auf dem Ciebirge war einmal ein Jager aufgefunden 
worden. Auf der Felsenwand in der Niihe der Sennhiitte, Senner und 
Sennerin hat ein eines schonen Tages ein von F'elsenwand achasant 
drihahol di ietal am droben auf der Wand. Vesuv, Vilz, Ventus, Verlend, 
Vaterland, Wist, Vogel. Veinstningerstadt, Venus, Vondertan Vogt, 
Vugler, Vangfiscb, Vidtrich, V'ersendung, Viendling, Vach, Vieh, 
Viehzucht, \'ersicherung, V'elzler, Vanter, Ente, Entrich, Elsass, 
Erlangen, Eidling, EidscJuvur, Eid, Endlang, Esel, Ellenbogen, Eiter, 
Edling, Entdeckung, Erfindung, Erdboden, Erdenhiigel, Erdenwall, 
Engel. (Tliere follow still forty-seven words beginning with E, partly 
(|uite senseless, then thirty-two words with U, thirty-five with K ; then 
comes DieWachtam Rhein, "Morgenrot," "Zu Strassburgauf der Schanz," 
" Ich hab' mich ergeben," " Der gute Kamerad," lastly 1 27 words beginning 
with K, twentvtwo with P, two with A, two with B, three with Sp, fifteen 
with W.) 

Besides the purely outward connection of ideas by 
similarity of sound there appears here clearly the persistence 
in the direction of the thought which has once come into 
view [mountain, huntsman, cliff, herdsman, Vesuvius and so 
on]. 

Stereotypy is shown in the frequent recurrence of the 
same turns of expression which occasionally are "done to 
death." A patient added on to everything ; " We Germans 
don't have that," another always answered, " Certainly, 
certainly," a female patient invariably interpolated " bitt 
schon." The following passage is another characteristic 
example : — 

" Ein venerisches Feldherrentalent, ein venerisches Arzttalent ; Sie 
haben liber zu sein, wenn ich will. Die Anstalt ist ein renerischcs 
Feldherrentalent ; ist sie nicht iiber, ist sie nicht fiber; sie ist nicht 
renerisch, iiber zu sein ; dann bin ich aber der L., wo ich iiber zu sein 
bin. Ich bin uber zu sein, was ich bin. Jeder Anstreicher ist hier am 
Geiste zu sprechen. Sie kommen hinausel ; das ist ja iiber Esel, hinausel I 
Und da ist dieser renerische Maler ; so tappig ist er am Geist zu sprechen, 
17-18 Jahre alt, iiber zu sein, was ich bin. Kein verniinftiges Wort ist 
iiber zu hOren im Geist. Einer muss iiber werden. Kommt da ein Baron, 
so ein Baron, der iiber sein will ; der is gar nicht iiber. Der ist ja gar 
nicht iiber zu sein, was ich bin ; der B. ist nicht liber : der ist eigentlich 
iiber was ganz gefahrlich iiber zu sein.'' 

In this .senseless rigmarole single words and phrases are 



PSYCHIC SYMPTOMS 63 

always brought forward again, sometimes exactly the same, 
sometimes with all sorts of changes, specially " iiber sein," 
" venerisch-renerisch," " Arzttalent-Feldherrntalent," " was ich 
bin," " im Geist-am Geist," " hinausel." 

If stereotypy is still more strongly pronounced, the morbid 
symptom of verbigeration is developed, the endless repetition 
of the same sentences, usually in measured cadence. A 
female patient repeated the following sentence from seven 
o'clock to half-past nine : — 

" I beg you to put me in another bed, in the bed where it was got 
ready yesterday ; else I shall not get out of hell any more. Jesus, dear 
Master mine, let me rely faithfully on thee ; lead me in the right path, 
O do lead me heavenward. You are my mother's lady's maid, and my 
mother is also there." 

If the endless repetition seems here to be partially ex- 
plained by the form of prayer, the following examples of 
verbigeration from the same patient show distinctly that it is 
a case of monotonous instinctive flow of speech : " Mutterle, 
fiihr mich ums Kirchlein herum bin um uns um zu ver- 
futtern," " Zar mein Milchen ums Eckbrett in alle Zimmer." 
Sometimes verbigeration takes the form of a senseless ringing 
of the changes on a syllable. A patient connected the follow- 
ing with the word " Bett " which was called out to him : — 

"Bett, Bett, Bett, dett, dett, dett, ditt, dutt, dutt, daut, daut, daut, 
dint, dint, dint, dutt, dett, datt. Wenn ich angefangen habe, fahre ich 
fort bis zu Ende." [When I begin, I continue to the end.] "Behindelt, 
bedandelt, bedundelt, bedindelt und bedandelt, umgewandelt, umgedan- 
delt, umgewandelt, umgedandelt. Krone, krone, krone, gekront, 
gekrbnt, gekront, gekrant, gekrant, gekrant, beschwant, beschwant, 
beschwant, sie sind beschwant und sind belohnt, sie sind betont, 
betonen, betonen, betonen, sie betonen, sie belohnen." " Es muss halt 
so sein, wenn es herauskommen soil." [It must just be so, if it is to 
come out ]. 

In writing also we again find stereotypy, it may be in 
frequent reappearance of the same expressions and phrases, 
or in innumerable slavish repetitions of the same strokes and 
words, sometimes with certain changes. Such an example 
is given in the specimen of writing 3. Besides the senseless 
persistence there is to be noticed here the peculiar spelling 
(" God " instead of " Gott,'' " Godhatz," " Godwilz," " Godiche 
kannz nicht Anders," " Willenz," " Sollenz," aber " Miissens "). 
The specimen of writing 2, as well as Figs. 10, 11, 12, show 
a less obtrusive stereotypy. From the writing of a patient, 
which will be discussed later, consisting partly of senseless 
accumulation of syllables, I take the following extract which 
exhibits the monotony of such productions : — 

" Von alien Rocky-Mountygrenzen ; in der ganzen Welt ; 9 Kim. 
(nach alien Massen). Von alien Catalonien-grenzen : in der ganzen 



64 



DEMENTIA PRECOX 



Welt : 9 Kim. (nach alien Massen). Von alien Hispanien-Neuspanien- 
San Juan — in der ganzen Welt : Seiten : Mittelpunkt : Ecken : u. s. w. 
9 Kim. (nach alien Massen). Von alien San-Salvator ; in der ganzen 
Welt : (Mittelpunkt : Ecken : Seiten : 9 Kim. nach alien Massen)" usf. 
It continues in the same way: "Von alien Mooderfontein," "Trans- 
vaal," '* Zinninseln," "Johannesburg," " Gewiirzinseln," "Zimmtbaum- 
inseln," " Unter alien mit Gras bewachsenen Rainlwschung,'' " unter 
alien europiiisch-asiatischen Kap," " Von alien Cappadocien : grenzen," 
" Baotokuten-grenzen," " Kanea-Kretagienzen," " Karfunkel (Amethist) 
gruben," "Kaplandpliitzen," "Garibaldis Ziegeninsel," "Unter alien 
Cottillontanzplatzen," " Panamarepublikgrenzen," " unter alien Pana- 
maskandalplatzen," "alien Lumpenfabriken," "alien Minen," "Adelaide- 
platzen," and so on and so on, invariably with the addition : " i'lberall in 
der ganzen Welt : 9 Kim. (nach alien Massen)." 

This senseless narration which endlessly repeats the same 



t^***«>^^ 




(Specimen of writing 3. Stereotopy). 

details deals with the country which it is " self-evident " the 
patient lays claim to for himself and his children. 

Negativism shows itself in the domain of speech 
activity, on the one hand in mutism, on the other hand in 
resistive or evasive ansivers. Many patients answer every 
question with another question or with " How ? " and then 
perhaps without further ado give the required information ; 
others simply repeat the question. Answers are often given 
that say nothing, are indefinite, or quite without relation to 



PSYCHIC SYMPTOMS 6$ 

the subject. Negativism appears more distinctly when the 
patients answer to all remarks, " I don't know " or " I don't 
need to tell you that." " You know that yourself already," a 
patient constantly answered, " I know everything, oui, oui." 
It frequently comes to " speaking past the subject." To 
the question always repeated; "How are you?" a patient 
replied in succession, " On the bridge," then " Mustardseed," 
next " Prayer-book," lastly, " Not at all ; I am sitting." 

Sometimes the patients obstinately maintain silence, as 
long as one is occupied with them, and begin to talk when 
one turns away from them, or they try to speak, utter a few 
words, but suddenly break off and cannot be moved to any 
further utterance ; a few patients speak with certain people, 
but are wholly inaccessible to others. Many patients speak 
low, scarcely move their lips, murmur unintelligibly to them- 
selves. In the end it comes to complete mutism, which lasts 
for months or years, but which may be suddenly interrupted 
by outbursts of the most violent abuse or screaming. In 
certain circumstances the patients in this state still give 
utterance in writing to their thoughts, sometimes expressing 
them comprehensively and for the most part very confusedly ; 
a patient declared that he wrote because he could not find 
words readily. As a rule, however, expression in writing is 
also suppressed by negativism. The patients cannot be 
persuaded to write at all, or they break off after a few letters, 
go playing over the paper, only scrawl a few unintelligible 
flourishes, or tap with the pencil on the desk keeping time. 
In measurements of pressure in writing one sees sometimes a 
continuous fall of pressure which is to be accounted for either 
by a simple failure of will-tension or by negativistic disorder. 
A patient wrote Roman mirror writing in order that no one 
might be able to read it. 

Linguistic movements of expression also seem to the 
patients to be often under the power of external forces. We 
have already stated above, that many patients are forced not 
only to think but also to say aloud what is suggested to them. 
Others "must" scream, "rage and abuse," call out suddenly 
" Halleluia," " Pfui " or " Kaiser and King " ; a patient " was 
obliged" involuntarily to "speak Bambergerisch." In the 
same way the patients sometimes cannot answer because 
the voices have forbidden them. 

Derailments in linguistic expression form a specially 
important domain in the speech disorders of dementia 
praecox. Vocal speech itself can be changed in the most 
varied way by side and cross impulses. The patients in 
speaking, bellow, screech, murmur or whisper, scarcely move 

E 



66 DEMENTIA PR/ECOX 

their lips, keep their teeth closed, or often pass suddenly from 
low whispering to loud screaming. The flow of speech is 
frequently hurried and rapid even in low speaking, sor^etimes 
varying quite irregularly, or speech is jerkily broken up, 
or produced keeping time with sharp rhythmical modulation. 
The cadence often lacks the risings and fallings, the melodies 
of speech ; the timbre of the voice may also be changed. 
The patients speak in falsetto, through their noses, in an 
artificial bass voice, pass suddenly from one key to another. 
Mignot rightly calls attention to the fact that the changes in 
strength of tone, height of tone, rapidity and rhythm in our 
patients are throughout lacking in that close relation to 
thought and mood, which in healthy people makes the voice 
such a pliant means of expression of inward states ; the 
individual peculiarities of vocal speech are changed without 
relation to each other or to the psychic occurrences by which 
they are usually ruled. 

Later there are introduced into speech not infreqyently 
clicking and smacking sounds, sniffing, and snorting, bleating 
words without sense, stock phrases with tiring repetition. 
Many patients speak affectedly with excessively distinct 
pronunciation, with distortion of single letters and with 
senseless intonation ; others of set purpose" in a childishly 
awkward manner, deliberately careless, indistinct, limp, or 
in the rudest dialect ; others again join on diminutives or 
other capricious additions, and still others speak in an 
unctuous preacher's tone. A patient mutilated and distorted 
the words, said "glank"' for "krank," " nuten Hag" for 
"guten Tag,"" Feinbeg" for "Heidelberg," spoke of the 
"Soktor" (Doktor) "Notessor" (Professor). Many patients 
answer singing; a female patient sang her own conversation 
and answers. 

In their zuritings there is found an arbitrary, peculiar 
disorder with whimsical misuse of punctuation marks and 
orthography invented by themselves. The letters show for 
the most part a very changing character, are sometimes 
large, and pretentious, sometimes small and scrawling, some- 
times irregular, slapdash or punctiliously uniform, as the 
specimens of writing given above show. Many patients 
write mirror-writing. Gregor found in his enquiries slowing 
of writing. The writing pressure also shows many oscillations. 
Gross was able to establish at one time very high, at another 
time very low pressure values, also lengthening of the pauses, 
and lastly extraordinarily great fluctuation of all value?, even 
in quite short periods of time, a sign of great fluctuation in the 
attention and volition of our patients. 



PSYCHIC SYMPTOMS 67 

Internal Speech. — But much more significant are the 
disorders of internal speech, of the transformation of ideas 
into Hnguistic movements of expression. The consideration 
of the disorders of speech in dreams has shown that the 
variety of such errors is very great. Unfortunately in 
dementia prsecox there have not been as yet any satisfactory 
enquiries into the corresponding phenomena ; nevertheless it 
seems to me that we find here the most important of the 
anomalies .observed there with surprising similarity. Certainly 
the difficulty of the interpretation is greater here, as we, 
unlike the experience of dreams, can seldom ascertain what 
the patient has exactly wished to say. 

Paraphasia. — We shall have to keep apart two chief forms 
of paraphasic disorders; ^xs\\y , derailments in finding words , 
secondly, disorders in connected speech. In the first group 
there may be, to begin with, a simple mutilation, a change 
or partial fusion of words in common use. A patient said : 
" Ich scham " instead of " Ich shame mich " ; another com- 
plained that he was " schmerzend, schadigt and genotigt " ; 
another spoke of " Reglierung." " Das Herz ist schwankig," 
" hilfbar " instead of hilfsbereit," " Zaubrigkeiten " instead 
of " Zauberei," "direktiv" ("I can't pronounce anything") 
instead of " direkt " are examples of word-transformations, 
A patient spoke of the " Wundneiarzt," when he was evidently 
bringing together "Wundarzt" and "Arznei"; another felt 
himself " kopfbewusstlos,'" " unbewusstlos." 

Another occurrence which is frequent in dreams, the 
substitution of one word for another usually similar in sonnd 
or meanings an occurrence which plays a large part in ordinary 
paraphasia also, is difficult to trace in our patients since the 
meaning of such utterances is mostly unrecognisable. But 
we may well suppose that many of the unintelligible 
expressions of the patients arise by paraphasic word- 
substitution, • They speak of the " Totenwahn," of the 
" Mondteufel," of the " Dolchmesser mit Hochzeitszettel," 
of the *' sozialdemokratischen Jagdstock," of the " souveranen 
Neuner," " Papstneuner." A patient worked " mit dem 
Vernunftgott " ; one felt himself " gaumenschwach " ; to 
another something appeared " schwarzwalderisch " ; a fourth 
declared, " Ihr seid Unterwalder"; a fifth called the physicians 
" Falschzugeschworene " ; a sixth said that a " Wecker vom 
Kriegsgericht " had been there ; a female patient complained 
that someone was pulling the " Frevelschnur." A male 
patient complained that his senses were " checked " ; " The 
doctor has collected my four senses." 

Neologisms. — There are intimations here already of a 



68 DEMENTIA PR/ECOX 

further form of paraphasia cleraihnent, which may become of 
very great extent in dementia pn-ecox, neologisms. In 
several of the examples quoted it \Veis already a case of new 
unintelligible words, but they were, however, composed of 
sensible component parts. (" Papstneuner," "gaumenschwach," 
" PVevelschnur ".) But there may be produced also quite 
senseless collections of syllables, here and there still having 
a sound reminiscent of real words. A patient spoke of the 
' Gestiibe und Angstbetrieb " ; another of the " Totendumpf " ; 
a third of the "Lebepuppe"; a fourth of the " Oxypathie," 
from which he was suffering ; a fifth was " krikeliert" ; a sixth 
did not want to belong " zur Tatowie " ; a seventh drivelled 
in an unintelligible way of " Reichsleben und Gerichtsleben.'* 
A female patient obstinately demanded " ihre Scheidung,. 
ihr Amtsgericht, ihr Jahr 1888, ihre Sallesichten und Sara- 
sichten " ; another complained about the " Physizieren und 
Mechanisieren," by which she without doubt wished to 
indicate sexual molestation. Many neologisms may, as 
happens in dreams, be expressions of more complicated or 
morbid ideas, for which no words exist. Formations such 
as " Aquinoktialhimmelskonigskind," " Wasserpadagogium," 
" Bombardongehiir," " Verkiirperungsunternehmen " make such 
a supposition probable. A patient explained that he would 
travel to Constantinople "auf dem Luftkompressionswege " ; 
another had " bengalische Gehirnerweichung durch Simulan- 
tenbehandlung" ; a female patient spoke of the "Glieder- 
auswachsung," and the " Blutvergiftungswas.ser." 

The tendency to silly plays on words and neologisms 
can get the upper hand in our patients to such an extent, 
that they fall into a wholly incomprehensible gibberish ; they 
usually then give it out as a foreign language which by slight 
changes in the syllables may be changed into any other you 
like. A patient gave as his first name, " Detscheneinaninad- 
renn." Another called himself, "Jesasus Christasusasus 
Heilandasus " and wrote down as his address " Aewa owa 
Ouwou Aewouwio sanco to totosaak saakiou sahaia siri tou 
toutou, Hoch Waiowauoxyowiiiowaiioxyoohoeho hachi hihi " ; 
it was the name of his castle. Another example is given in 
the following fragment from a petition to the district court 
which began at first quite sensibly : — 

"Urrass Asia peru arull ptlluss Pisa anueil pelli. 

" Madrass ihsa Peru parell mull illuss thesu thariass inehluss pinta 
aperu ailesa, medut prusa exel ill Farrawall. 

" Cap Nansen ell Pisa uruhl nell palle ixo piso panthe alluss pesass 
esu lull maxima perrett ill panse arruse ill perrell Thatciduss usa ihru 
maltell pe uxa thyrra, pia apenlia ruhsa iss tlietu, cralluss Asia peni vendi 
arrull, mesa. Uss Adda pia mellu Exter a probro ; Mess Killian esu 



PSYCHIC SYMPTOMS 69 

panein Dante, illo pisa thesu arrendt, mess pasi Ural pill palli mesa essu 
Acus Cantone, cU Albydill, Anscliill, Kulla Apia Nestor," and so on. 

In this senseless collection of syllables there are scattered 
a number of correct or somewhat altered proper names 
(" Asia," " Pisa," " Madrass," Peru, Nansen, Adda, Exter, 
Killian, Dante, Ural, Apia, Nestor, Farrawell, Thatciduss, 
Albydill) ; some (Pisa, Asia) appear again, as also a series of 
other newly formed words (arull, perell, ill, thesu, mesa, esu, 
pia). There are also innumerable similarities of sound 
(pellus-pelli-pill-palli, mehluss-alluss-cralluss, arull-uruhl- 
arruse-ruhsa, peru-perell-perett, pinta-panthe-apentia-peni- 
penem-pasi), though not in unbroken sequence, but like the 
repetitions scattered irregularly thoughout the whole series. 
If the whole comprehensive piece of writing had been 
reproduced, that would have been still much more distinct. An 
inner connection is only recognisable in so far as the names 
introduced all apply to towns, countries or persons ; in Farewell 
(" P^arrewell ") and Cap Nansen there could also perhaps 
be found a still nearer relation. The patient interrupted his 
gibberish with the remark, " Now again to the subject " and 
then writes of his "discoveries," among which a great number 
of countries are mentioned; he concludes with more gibberish 
as above. In the middle sentence there is the following 
silly play on words ; " Puntas : Punte : Punto : Punti : Punta : 
Puntes : Puntal : Puntales : Puntu : Punto : Puntel : Puntelus." 

Sometimes it comes to senseless rhyming as in the 
following transcript : — 

"Sei ruhig, ich werde ein lichter Trager mit seiner dummes Zeug 
Klager — er fetter schon die Arm im Schnauzen mit seiner gimmen 
guten Bauzen. Er hat nicht schlucken voll Erbarmen aus voller 
Schmerz in seiner Karmen — Von Lichter schlagt er mir die Lichter in 
Donnerwetter HoUenrichter, ein Donnerwetterrichter, ein schwarzer 
Seljon ein Secht in meine Hinterlader spricht einst ein junger halb in 
Krater. Ein Vater Himmel Donnerwetter Licht — ich lade alle Teufel 
aus und trug die HoUenmarke naus." 

This wholly incomprehensible talk made up of neologisms, 
similarities of sound, rhymes and repetitions brings to mind 
the speech of dreams as also the reading of a delirious 
alcoholic from a blank page. We find the same thing again 
in the next piece of writing: — 

"Weiss blau bin ich gnau soh der Pfau. Weiss und gelb soh die 
Quell. Schwarz und weiss soh das Eis. Rot und schwarz soh der Bass 
und soh das Fass. Weiss wieh Schnee rot im Kleeh soh die Hoh oh 
welches Gliick. Miiuschen grau rot und grau rot und blau. Wenn 
und wann soh die Tann. Holz zum Kranz soh der Tann. Mauschen 
gleih soh das Blau." 

Almost still more peculiar do the lyric poems appear to 



70 DEMENTIA PR.4£COX 

us, which a female patient composed in a language invented 
by herself, though usually she could express herself without 
difficulty. I give one verse here : — 

Stanzuru vimmt den Bark zum Obendrob 
Heuschend lagert ein Bigart im Striehen Obss 
Leulend, lagcrnd, bimmt die Bimbii im Hyurisch 
Bordent blickt Aug iin Drugsag des Auggehoks 
Rastand blickt die Staniza im Herz eingelallt 
Schwiichend irit Corpus im trausen Laufgedalt 
Zu einein armen kranken Cornt von Erdgedob. 

A few words ("Bark," "lagert," "blickt," "Aug," 
" rastend," " Herz," and so on) are still intelligible, but for 
the most part it is a case of wholly senseless neologisms. 
At the same time a certain tendency to assonance and a 
childish playing with sounds cannot be lost sight of 
("vimmt — bimmt — Bimbii." "Obendrob — Erdgedob," "Stan- 
zuru — Staniza," "Aug — Auggehoks," "Corpus — Cornt," 
eingelallt, — gedallt,"" heuschend — leulend — lagernd — bordent, 
— rastend — schwachend "). 

Akataphasia. — Not less worthy of note than the disorders 
in word-finding are those which influence in a morbid way 
the form of speech. At first we have to do with those 
derailments in the expression of thought in speech which we 
call akataphasia. In this case the patients either do not find 
the expression appropriate to their thoughts, but only 
produce something with a similar sound ("displacement 
paralogia"), or they let their speech fall into quite another 
channel ("derailment paralogia"), A patient said he was 
"wholly without head on the date "for "he did not know 
the date " ; another complained he " lived under protected 
police" instead of "under the protection of police" a third 
declared to his father he " was the greatest judicial murder" 
instead of " on him the greatest judicial murder was practised," 
Similarly a patient remarked he was "the disguise in all 
ways " instead of " he had disguised himself in all ways." 
Another patient said he had "his fiancee always in speech" 
instead of " his fiancee still continued to speak to him " 
(through voices) ; a female patient asserted she knew " in a 
miracle" that her father w^s a priest instead of 'she had 
learned it in a miraculous way. ' To this series also the 
expression of a patient mentioned before belongs, he " toned 
with God," instead of "he heard tones from God." and the 
utterance of another that he " was instructed in the experi- 
mentally approved specialty." 

The following utterances give us ground for concluding 
that the expression of thought in speech glides off into side- 
ideas which intrude themselves ; " I have a suspended 



PSYCHIC SYMPTOMS 71 

appetite," " I have voluntary disease of the eyes," " They 
are threaded at the head," " I am national-Hberal chased 
away." A patient said that he had danced, " lay in morti- 
fication." To this group should perhaps be reckoned some 
of the bevvilderingly nonsensical utterances, which were 
quoted above as examples of the incoherence of speech of our 
patients, and which apparently represent a sen.seless jingling 
of words. A patient used the word "Log" a great deal 
and explained that it was shortened from " logic," and then 
leaving the track he continued " Lot-overlog-underlog ; philo- 
logists have outlived themselves ; these are individual 
expressions." Here the relation to childish playing with 
sounds is distinct. 

Construction of Sentences. — A further form cf impair- 
ment of speech springs from disorder in the construction of 
sentences. In the examples of incoherence of the train of 
thought which were given before, the syntax is also confused 
in different places (" Former service and then she does it," 
" I, and that is also so curious, therefore the nun." " I should 
come from M. because always something happens, leg broken 
or something, they have quarrelled," "as I that at last of 
those that particularly believe"). A patient wrote in an 
anonymous letter, " Mortimer in reference to two kings " ; 
another said he was sad "on account of the national economic 
interests, concerning foreign commerce." In more pro- 
nounced disorder speech may develop into the style of a 
telegram, doing without all superfluous phrases, and in the 
end there may be complete disappearance of sentence- 
formation. An example of this is given in the following 
petition to the chief of the police which is called " Cabinet 
affair honesty " : — 

" By the grace of God are the Emperor of the present analogy 
of the spirit 'in spiritu' of radical sworn upon oath subjects of proved 
alarm-satisfaction of my stamped masculine disposition 'centre Calvin ' 
of academic birth-stamp of analogy of party liable to military service 
of declarative property customary of honest palatinate despotism of the 
highest of all honesty 'contrary disposition' of freely intelligently 
right of acquisition of foreign rank of financial-joint legal contract of 
psychiatric truth of forgotten wound-fever of frugally imperial bureaucracy 
of secured-capital profitable persecution of the Christians most obediently 
S,, imperial parliamentary IV. service-laced prize-seal. Affair of an 
oath I Radical 'brevi manu '! " 

In this singular piece of writing besides the verb "sind" 
only dependent genitives are found as the one indication of 
syntax. For the rest it swarms with newly-formed compound 
words, the parts of which in themselves are rational (Geistes- 
analogie," " radikaleidlich," " Alarmgenugtuung," " meinge- 



72 DEMENTIA PR/FXOX 

stempelt," and so on). " Geistesanaloijie " is soon followed 
by " Parteianalogie," " meingestempeit " by " Geburtsstempel," 
•' Mannesgesinnung " by " Gegengesinnung." " radikaleidlich " 
by " Eidessache " as indication of the persistence which is 
invariably noticeable in such documents. " Dienstgeschnurte 
Prisensiegel " might be regarded as displacement paralogia 
(" Dienstsiegel "). The whole is a sample of confusion of 
speech in which moreover, in spite of complete want of 
connection, there is still a certain general colouring of the 
ideas recognisable. 

Train of Thought. — The last group of examples brings 
us to derailments in the train of thought itself, which 
certainly often accompany the forms hitherto discussed. 
As already mentioned, we hear from our patients a great 
many quite imcomprehensible and disconnected utterances, 
in which it can scarcely be only a question of disorders of 
linguistic expression, even though it is impossible in the 
individual case to discover the inner mechanism by which 
the utterances arose. Thus a patient spoke of the " brain- 
navel of the merchants' association " ; another said, •' One 
cannot take the direction from the reflection." But some- 
times a derivation of the train of thought from the scries of 
ideas which is immediately present, to another, as frequently 
happens in dreams, is clearly seen. A patient when asked 
what year it was, replied, " It may be Australia," wandering 
from the series of years to the series of continents ; another 
to the question what month it was, answered Strassburg. A 
third complained that the attendant had " forced the tax- 
duty " on him, and .so passed from the idea of some sort of 
unpleasant influence to that of paying taxes. Perhaps the 
utterance of defence made by a patient " Get away from the 
reins " is to be regarded in a similar way, in as far as the 
approach of anyone awakened the idea of the putting on of 
reins. When a patient said, " Suffering hunger is stronger 
than in all deaf-mutes," the supposition may be made that 
here the idea of deaf-mutes has taken the place of a more 
general thought comprehending want or misfortune. Also 
the saying, " I have gone through much for the German 
language," may be considered as a derivation of the train of 
thought, as also the expression relating to some or other 
indifferent occurrence ; " That can be written with blue ink." 

One will scarcly go wrong if one assumes a derivation in 
those forms of talking past a subject, in which a negativistic 
evasion of the right answer is not clear. A patient replied 
to the question in which town the hospital was by .saying, 
" The house stands in the gospel of Luke of the eighth, and 



PSYCHIC SYMPTOMS 73 

if one has swine, one can slaughter them." [German . . . 
des achten . . . schlachten.] Here after the first derivation 
of the train of thought to another domain of ideas another 
follows which is conditioned by the rhyme. The same 
patient on being asked to enumerate the names of the 
months, did so in the following manner : " Jas je ji jo jan jan 
dran drin draus dann Mainz, dann Worms." He first fell 
into the vowel series, then into similarities of sound and into 
practised combinations of letters (" drin-draus "), and lastly, 
into the enumeration of names of towns. 

From these disorders the transition is easy to those 
pnenomena with which we became acquainted before as 
speaking past a subject. Here it is no longer the transference 
to expression in speech that is morbidly influenced, but the 
ideas aroused by the circumstances are themselves already in 
their origin pushed aside or suppressed by ideas related but 
lying remote or opposed to the original ones. 



CHAPTER III. 

GENERAL PSYCHIC CLINICAL PICTURE 

Now if we make a general survey of the psychic clinical 
picture of dementia pr.tcox, as it has presented itself to us 
in the consideration of about a thousand c'ases which belong 
to the subject, there are apparently two principal groups of 
disorders which characterise the malady. On the one hand 
we observe a iveakening of those emotional activities ivliich 
pennanently form the mainsprings of volition. In connection 
with this, mental activity and instinct for occupation become 
mute. The result of this part of the morbid process is 
emotional dulness, failure of mental activities, loss of mastery 
over volition, of endeavour, and of ability for independent 
action. The essence of personality is thereby destroyed, the 
best and most precious part of its being, as Griesinger once 
expressed it, torn from her. With the annihilation of 
personal will, the possibility of further development is lost, 
which is dependent wholly on the activity of volition. What 
remains is principally what has been previously learned in 
the domain of knowledge and practical work. But this also 
sooner or later goes to ruin unless the failing inner main- 
spring is replaced by outer stimulus which rouses to continual 
practice and so obviates the slow disappearance of ability. 
Whether and how far the malady directly injures the mental 
faculties apart from their gradual disappearance through disuse 
of mental function needs further inquiry. The rapidity with 
which deep-seated and permanent dementia sometimes 
develops in the domain of intellectual work makes the 
suggestion easy, that it also may itself be drawn by the disease 
into a sympathetic morbid state, even though it is invariably 
encroached on to a much less degree than emotion and 
volition. It is worthy of note in any case, that memory 
and acquired mental proficiency may occasionally be 
preserved in a surprising way when there is complete and 
final destruction of the personality itself. 

The second group of disorders, which gives dementia 
prsecox its peculiar stamp, has been examined in detail 
especially by Stransky.^ It consists in the loss of the inner 

' StTiinksy. Jahrb. f. Psychiairie, xxiv., 1903, i ; Wiener nied. I'resse 1905, 28. 



GENERAL CLINICAL PICTURE 75 

unity of the activities of intellect, emotion, and volition in 
themselves and among one another. Stransky speaks of an 
annihilation of the " intrapsychic co-ordination," which is 
said to loosen or destroy the articulations of the " noopsyche " 
and the " thymopsyche " themselves as well as their mutual 
relations. This annihilation presents itself to us in the 
disorders of association described by Bleuler, in incoherence 
of the train of thought, in the sharp change of moods as well 
as in desultoriness and derailments in practical work. But 
further the near connection between thinking and feeling, 
between deliberation and emotional activity on the one 
hand, and practical work on the other is more or less lost. 
Emotions do not correspond to ideas. The patients laugh 
and weep without recognisable cause, without any relation to 
their circumstances and their experiences, smile while they 
narrate the tale of their attempts at suicide : they are very 
much pleased that they "chatter so foolishly," and must 
remain permanently in the institution ; on the most in- 
significant occasions they fall into violent terror or outbursts 
of rage, and then immediately break out into a neighing 
laugh. It is just this disagreement between idea and 
emotion that gives their behaviour the stamp of " silliness." 
Stransky traces the soiling of the bed also to a morbid 
connection of this procedure with feelings of pleasure. 

The work of the patients is not as in healthy people the 
expression of their view of life and temperament, it is not 
guided by the elaboration of perceptions, by deliberation and 
moods, but it is the incalculable result of chance external 
influences, and of impulses, cross impulses, and contrary 
impulses, arising similarly by chance internally. A patient 
sang as he jumped into the Neckar ; others burn or scatter 
their money, try to cut the throat of a beloved child, or with 
pitiful screaming maltreat themselves in the most regardless 
way. The phenomena of paramimia belong to this group also, 
the side activities, as well as the oddities which result from 
them, but especially do the disorders of inner speech find 
their place here, which may likewise be understood from the 
point of view of a relaxation of the relations between idea and 
actual speech. By this destruction of inner concatenation and 
causation the whole of active life receives the stamp of the 
incalculable, the incomprehensible, and the distorted. 

As it seems to me, there exists an inner connection between 
the two groups of disorders, which are here distinguished. 
What fashions our experiences into a firmly mortised 
building, in which each part must fit the other and sub- 
ordinate itself to the general plan, are general conceptions 



76 DEMENTIA PR^ECOX 

and ideas. The even calm of our temper, the swift victory 
over sudden shocks, are guaranteed by the higher general 
emotions ; on the one hand they work by acting as a check, 
and on the other hand they give to the background of our 
mood a definite colouring even when no emotional stimuli 
are caused by special internal or external experiences. 
Lastly, the inner unity of our will is conditioned by the 
general trend of volition which is always alive in us, and 
w hich is the product of our racial and personal development. 
We may therefore expect that a weakening or annihilation 
of the influence which general conceptions, higher emotions, 
and the permanent general trend of volition exercise on our 
thinking, feeling, and acting, must draw after it that inner 
disintegration, those " schizophrenic " disorders, which we 
meet with in dementia pra^cox. It seems to me that the 
disorders observed in the patients and the complaints to 
which they give utterance, point exactly to injury to the 
general scheme of our psychic development, as it fixes the 
substance of our personality. The general trend of volition 
and also the higher emotions might form the first point of 
attack. But further the instrument of general conceptions 
with its regulating influence on the train of thought would 
then also become worthless, if the will were no longer capable 
of using it. Weygandt speaks, obviously following a similar 
line of thought, of an " apperceptive dementia " in as far as 
the injured " active apperception " signifies the dominion of 
volition over the formation and the course of psychic 
processes. 



CHAPTER IV. 
BODILY SYMPTOMS. 

Besides the psychic disorders there are also in the 
physical domain^ a series of morbid phenomena to record, 
whose more exact relations to the fundamental malady are 
not yet, it must be admitted, proved in all points. 

Headaches are frequent, to which Tomaschny has 
specially directed attention ; they are referred to forehead 
and temples, but also to the vertex or the occiput, mostly in 
the form of oppression, a pressing together. To these may be 
added unpleasant sensations of all kinds in the most different 
parts of the body, of which we have to a certain extent made 
mention already, also those irritative phenomena which are 
so frequently present in the higher mechanisms of sense. 
Sensitiveness to pain seems not infrequently diminished, even 
though no certain opinion can be arrived at owing to the 
psychic dulness of the patients ; Mayor often found tender- 
ness in the hypogastrium and the breasts. 

Behaviour of the Pupils. — This is of great significance. 
They are frequently in the earlier stages of the disease and 
in conditions of excitement conspicuously wide, according to 
IVJeyer in lo per cent, of the cases, as Weiler explains, 
t)ecause of an increase, caused by the morbid process, of that 
cortical excitement which reduces the tone of the sphincters. 
Here and there one observes a distinct difference in the pupils. 
The light-reaction of the pupils'^ often appears sluggish or 
slight. Westphal sometimes found distortion of the shape of 
the pupils, obliquely oval position, and also passing failure of 
the reaction to light and accommodation especially in states 
of profound stupor, sometimes unilateral, sometimes bilateral. 
He suggests morbid tension of the musculature of the iris in 
connection with the general muscle tension. According to 
Sioli's observations similar disorders can be produced even 

^ Trepsat, Etude des troubles physiques dans la demence precoce. These. 1905 ; 
Tomaschny und Meyer, Allgem. Zeitschr. f. Psychiatrie, 1909, 845 ; Pfortner, 
Monatsschr. f. Psychiatrie u. Neurol, xxviii. 208 ; Serieux, Annales medico- 
psychol. 1902, Nov. -Dez. 

2 Westphal, Deutsche medizin. Wochenschr. 1909, 23; Bumke, Miinchener 
medizin. Wochenschr. 1910, 51 ; Weiler, Zeitschr. f. die ges. Neurologic und 
Psychiatrie ii., lOl. 



78 DEMENTIA PR/ECOX 

after the disappearance of the stupor by strong voluntary 
straining of the muscles. All the disorders which have been 
mentioned appear to be subject to much change. 

The pupillary reaction to pain and psychic stimuli as well 
as the pupillary movement which continuously accompanies 
the psychic life has disappeared, as Bumke found, in a 
considerable number of cases. It must be allowed that the 
statements about the frequency of this disorder are extra- 
ordinarily discrepant which, considering the difficulty in 
ascertaining the facts, does not appear surprising. Bumke 
did not once find the psychic reactions normal in 33 cases, 
in 69 per cent, he found it lost ; he states that first the 
pupillary movement, the permanent slight variation of the 
width of the pupils, which is only recognisable with the loupe, 
disappears, then the dilatation of the pupils caused by 
psychic impressions, lastly the pain reaction. Hiibner failed 
to get the psychic reflexes in 75 per cent, of 51 cases. Still 
higher numbers were got by Sioli who found in 48 cases 
belonging to the domain of dementia priecox the psychic 
reaction and the pupillary movement absent. On the other 
hand, Wassermeyer in 39 cases observed absence of the psychic 
reflexes only in 1 5 per cent. VVeiler saw it in 36 per cent, of 
126 cases; in another 20 per cent, they were diminished. In 
detail it was shown that absence of pain reaction could be 
ascertained only in 36 per cent., a diminution in a further 
20 per cent.; against that an increased reaction on psychic 
and sensory stimulation in 40 per cent., a diminution in 
34 per cent, of the cases. The disorders of all these reactions 
appeared 24 times among 35 hebephrenics, 41 times among 

79 catatonics, 6 times among 12 paranoids; they were there% 
fore most frequent among the first. Weiler is inclined to 
account for the numerical difference of his results from those 
of other observers, disregarding slight differences in the 
carrying out of the observations, essentially by the circum- 
stance that he had mostly more recent cases. The dis- 
appearance of the reaction was observed in general more in 
advanced stages of the disease, but was occasionally to be 
seen in the early periods. One can scarcely be mistaken, if 
one brings this failure of the psychic reaction into connection 
with the disappearance of the emotional activities in our 
patients, by which they are probably caused. It must, 
however, be noted that Wassermeyer in 174 healthy soldiers 
could establish in 6 cases a considerable diminution and once 
absence of the psychic pujiillary reaction, while Sioli found 
it present in 25 attendants, though to a very varying 
degree. 



BODILY SYMPTOMS 79 

The tendon reflexes are often more or less considerably 
increased, according to Meyer in 45 per cent. ; according t(j 
Trepsat in 59 per cent; diminished in 14, relatively 12 per 
cent. Weiler often got, especially in stuporous patients, 
absence of the brake-action, and in consequence repeated 
after-oscillation. Meyer found in 398 cases patellar-clonus 
6 times, ankle-clonus twice. Skin and mucous membrane 
reflexes are often weak ; Trepsat found the plantar reflex 
in 64 per cent, of the cases diminished, in 26 per cent, 
increased. 

Psycho-motor Domain. — Various and profound disorders 
are found here. Dufour has described disorders of equili- 
brium, staggering, adiadochokinesia, and tremor, which he 
regards as the expression of a " cerebellar " form of dementia 
praecox. Ermes ^ has recorded curves of attitude in cataleptic 
patients. He found that a fall of the leg held horizontally 
only began after 205 seconds, while in healthy persons it 
made its appearance on an average after 38 seconds, at latest 
after 80 seconds. There followed then either a repeated 
jerky falling off" with tremor or a gradual sinking. Before 
complete relaxation 20 minutes elapse with the patients; in 
healthy persons rather more than 7 minutes. The principal 
cause of this power of endurance is certainly to be sought for 
in peculiar disorders of volitional impulse. Meanwhile 
Ajello^ has after very comprehensive investigations arrived 
at the result, that the muscles of those patients, whom we 
shall later come to know as catatonics, show a peculiar 
reaction to electrical stimuli. It consists according to his 
experiments in the simultaneous appearance of tonic con- 
.tractions along with genuine muscle-twitchings. He connects 
this phenomenon with a heightened irritability of the 
sarcoplasm, as it is only found otherwise in embryonic, 
fatigued, anaemic, or degenerated muscles, and he brings it 
into relation with the idiopathic muscular swellings, which 
indeed can be demonstrated not infrequently in our patients 
at the same time as heightened sensibility of the muscles to 
percussion. 

Gregor and Hansel found in experiments with the 
et'gograph that the patients made only a few curves of 
approximately the same height, and then suddenly gave out. 
Isserlin and Lotmar have investigated the course. of simple 
flexion and extension movements of the right index finger in 

^ Ermes, Uber die Natur der bei Katatonie zu beobachtenden Muskelzuslande. 
Diss. 1903. 

^Ajello, Ricerche sulle proprieta fisiologiche generali dei muscoli nella 
catatonia, 1907. 



8o DEMENTIA PRECOX 

our patients. Fig. 13 ' shows the course of a finger movement 
consisting of flexion and rapid extension in a healthy person ; 
Figs. 14 to 17 the same iu catatonic patients ; the rapidity of 
the revolving drum which in Fig. 15 is reproduced in fifths of 
a second was in all approximately the same. Fig. 14 shows 





Fk;. 14. 
Simple Finger Movement in Catatonia {a). 



Fig. 13. Normal F"inger Movement. 

apart from the smaller excursion of the movement, an 
abnormality which frequently appears in catatonics, though 
not invariably, the interpolation of a perceptible pause 
between flexion and extension which always follow each 
other immediately in healthy persons, at the same time 




Flc. 15. Simple Finger Movement in Catatonia (d). 



extension is slower than normal. We are here reminded of 
the stiffness and rigidity which strike us so frequently in 
catatonic movements. The abnormalities seen in Fig. 15 
are much greater, though certainly they do not appear so 
frequently. Here there is first a preliminary extension before 
flexion, that is an opposing impulse which is seen in 
healthy persons, as in Fig. 13, at most as a slight " depression." 

' The whole series is reduced two-thirds. 



BODILY SYMPTOMS 



81 




Fig. 1 6. 
Simple Finger Movement in Catatonia (< ). 



The recoil of the finger immediately succeeds flexion, but it 
is suddenly checked in the middle of its descent and then 
the finger returns with oscillations to the original position. 
The straightforward course with which the required move- 
ment is performed in 
healthy persons is ac- 
cordingly influenced in 
patients occasionally by 
all sorts of counter im- 
pulses and checks. The 
other curves got from 
the same patient, as they 
are reproduced in Figs. 
1 6 and 17, .show still 
other results. In Fig. 16 
a repeated oscillation of opposing impulses meets us ; at the 
end the finger persists in the flexed position. Fig. 17 shows 
a similar proceeding after a movement of flexion carried out 
correctly at the beginning. Among these curves there were 
frequently some that followed a normal course. 

Rhythmical movements 
also, which in healthy per- 
sons run their course in 
the form of flexion and 
recoil just like a machine, 
show at the transition to 
extension the same hesita- 
tion as the simple"reaction 
movements." Fig. 18 
represents such a series of 
continuous pendulum 
movements, which keep 
time, of a finger of a healthy person ; Fig. 19 shows the 
same in the case of a catatonic; the time record which is 
reproduced gives the hundredth parts of a second. 

The seizures which have already been very well described 
by Kahlbaum and Jensen deserve special notice. They are 
mostly attacks of vertigo, fainting fits, or epileptiform con- 
vulsions, which occur in our patients, sometimes as an 
isolated occurrence, sometimes more frequently. More 
rarely there are spasms in single muscle groups (face, arm), 
tetany or even apoplectiform seizures with paralysis which 
lasts for a considerable time, but I was told of some such 
cases in the previous histories. Once I saw profound 
collapse with spasms on the left side and in the right facial 
nerve. A seizure is not very infrequently the first sign of 

F 




Fig. 17. 
Simple Finger Movement in Catatonia (d). 



82 DEMENTIA PR/ECOX 

the approaching disease. 1 observed among others the case 
of an older student who had been specially gifted from youth. 
He was suddenly attacked by profound coma from which he 
only gradually awoke. Except for a slight difference in the 
pupils, facial phenomenon, and great increase of the refle.xes, 
there was no trace of cerebral symptoms, but when I 




Fig. i8. Normal Rhythmical Finger Movements. 

examined the patient a few weeks later, he exhibited the 
well-marked picture of premature weak-mindedness, which 
continued for years. Hiifler describes also equivalents of 
catatonic seizures, in which lie includes transitory disorders 
of the innervation of the arm, of the musculature of the face, 
of the tongue, panesthesiae, pains, vascular and pupillary 




Fn;. 19. Rhythmetical Finger Movements in Catatonia. 

disorders, vomiting, attacks of sweating with or without 
clouding of consciousness. All these seizures are more 
common in the female sex than in the male. I found them 
in my series in about 16 per cent., and in the Heidelberger 
patients, who were observed for a longer time, in 19 per 
cent, of all cases. But besides that in a whole series of 



BODILY SYMPTOMS 83 

patients (6 per cent, of the men, 3 per cent, of the women) 
spasms or fainting fits had occurred previously in youth, 
about which it must for the present remain doubtful whether 
any connection with the psychic disorder may be ascribed to 
them. Some patients had suffered from chorea. Urstein 
records seizures in 8 per cent, of the men and in 19 per cent, 
of the women. In one case I saw the development of a 
profound catatonia after the existence for many years of 
undoubted epileptic seizures to which then hysteroid seizures 
were added. And otherwise hysteroid spasms and paralyses 
are often observed besides aphonia, singultus, sudden erection, 
local contractures, and similar phenomena. 

The spasmodic phenomena in the musculature of the 
face and of speech, which often appear, are extremely peculiar 
disorders. Some of them resemble movements of expression, 
wrinkling of the forehead, distortion of the corners of the 
mouth, irregular movements of the tongue and lips, twisting 
of the eyes, opening them wide, and shutting them tight, in 
short, those movements which we bring together under the 
name of making faces or grimacing; they remind one of the 
corresponding disorders of choreic patients. Nystagmus may 
also belong to this group. Connected with these are further, 
smacking and clicking with the tongue, sudden sighing, 
sniffing, laughing, and clearing the throat. But besides, we 
observe specially in the lip muscles, fine lightning-like or 
rhythmical twitchings, which in no way bear the stamp of 
voluntary movements. The same is the case in the tremor 
of the muscles of the mouth, which appears sometimes in 
speaking and which may completely resemble that of 
paralytics. In a great number of patients 1 observed distinct 
twitchings of the musculature of the mouth on tapping the 
lower branches of the facial nerves. Occasionally one sees 
uneven muscle- tension on the two sides of the face 
temporarily or for a longer time, on which Hufler has laid 
stress. The out-spread fingers often show fine tremor.. 
Several patients continually carried out peculiar sprawling, 
irregular, choreiform, outspreading movements, which I think 
I can best characterise by the expression " athetoid ataxia." 

Aphasia. — In two cases it was possible during a sf:ate 
of dull stupor to demonstrate distinct aphasic disorders. 
The patients were unable to recognise and to name the 
objects laid in front of them although they could speak 
and were evidently exerting themselves to give the required 
information. Repeatedly after long consideration the wrong 
names came out. The disorder disappeared again after a 
few hours. 



84 DEMENTIA PRECOX 

Vasomotor disorders are very wide spread in our 
patients. Above all one notices cyanosis of the hands, less 
of the feet, the nose and the ears ; from the deep blue 
colour of the skin, dilated arterial areas are sometimes dis- 
tinguished as bright red, sharply circumscribed spots, which 
can be artificially produced by pressure. Further there are 
found circumscribed areas of oedema, congestion of the 
head, vivid blushing, dermatography in all degrees, especially 
in the beginning of states of stupor. Trepsat was able in 
one case after 48 hours to make the dermatographic writing 
again visible by light rubbing with the finger-tip ; he reports 
also eruptions and even ulcers of " trophic " origin. The 
activity of the heart is subjected to great fluctuations ; 
sometimes it is retarded, more frequently it is somewhat 
accelerated, often also it is weak and irregular ; many patients 
complain of palpitation. 

Blood-pressure is as a rule lowered ; it fluctuates, how- 
ever, considerably. Weber found for systolic and diastolic 
pressure, pulse pressure and pulse frequency low or at most 
average values especially in stuporous patients. Lugiato 
and Ohannessian, as well as Lukacs, were able to ascertain 
frequently a disproportion between blood-pressure and pulse 
frequency. Bumke and Kehrer observed in plethysmo- 
graphic experiments in catatonic stupor absence of decrease 
in volume, as well as of changes in pulse and respiration, on 
the application of the stimuli of cold and pain, and they 
point out the relationship of this disorder to the absence 
of the psychic pupillary reaction. 

Respiration is according to d'Ormea's statements some- 
what accelerated and very deep, and it shows many irregu- 
larities especially in expiration. Sometimes severe outbursts 
of perspiration are observed. 

The secretion of saliva is frequently increased, usually 
only temporarily, much seldomer permanently ; I was able 
from one patient to collect in 6 hours 375 ccm. of saliva. 
The analysis carried out by Rohde in one case gave a 
specific gravity of 1*0026 and a nitrogen content of oigi 
per cent., values which are at the lower limit of the normal, 
and do not point to the origin of the flow of saliva b)' 
stimulation of the sympathetic. In some patients rumina- 
tion is observed, especially in the terminal states. 

Temperature is usually low, sometimes sub-normal with 
occasional reversal and small range of the daily fluctuations. 
Fig 20 shows the course of the temperature in the last 
weeks of life of a patient who was considerably excited and 
who did not exhibit any apparent bodily ailment. The 



BODILY SYMPTOMS 



85 



readings, which had already for more than 3 weeks previously 
almost always been under 37" C. and on one occasion had 
sunk to 34"2'' C, are repeatedly lower in the evening than 
in the morning ; they sink in the two last weeks of life first 
to 33"4'' C. and then with a single jump rise again to 38'5'' C. 
and even to 39 i" C. towards the end of life. 

The menses are usually absent or irregular, according 
to Pfortner's statements in two-thirds of the recent cases. 

Blood Changes. — The obscurity that hangs over the 
causes of dementia praecox has been a frequent motive for 
the examination of the blood-picture and of metabolism, 
but the findings up to now are not very satisfactory. Lund- 




10 11 12 13 14 15 16 17 18 19 20 21 II 23 24 25 



Fig 20. — Course of the body temperature at the close of life of a catatonic 

patient. 

wall found in general no change in the blood, but '• blood 
crises" with decrease in the red and increase in the white 
corpuscles which appeared periodically. Bruce and Peebles 
describe in the acute periods of the disease a moderate 
increase specially of the polynuclears and the large mono- 
nuclears, which in stupor, but still more in the terminal 
stages, gives place to a decrease, specially in the pclynuclear 
leucocytes. Bruce has even made the attempt to establish 
blood-pictures peculiar to each form of insanity and from 
them to draw prognostic conclusions, an undertaking, which 



86 DEMENTIA PR/ECOX 

in face of the many diverse statements must be regarded 
as premature. Heilemann also reports a small increase of 
the white blood cells with comparative decrease of the 
polynuclear forms. Sandri emphasised similar findings 
especially in catatonic states. Dide and Chenais' observed 
an increase of the eosinophil cells, Pighini and Paoli an 
increase in the size of the red blood corpuscles with a ring- 
shaped arrangement of the haemoglobin. Itten was not 
able to establish any characteristic findings in the blood. 
However, in some chronic, resistive, demented patients fairly 
high leucocyte counts were found, and in some dull depressed 
patients comparatively low counts. 

Berger has made the attempt to prove the presence of 
to.xic material in the blood of catatonics by injecting serum 
of the patients into the occipital lobe of dogs ; he found 
that muscle twitchings, apathy and a tendency to forced 
attitudes appeared. 

Investigations in metabolism - have also frequently been 
carried out. In acute cases Pighini observed increased 
excretion of nitrogen, phosphorus, and sulphur, of urea, uric 
acid, and xanthin bases, which he connects with increased 
breaking down of nucleoproteins containing phosphorus 
and sulphur. Allers has called attention to the fact that 
here possibly insuflficient nourishment might play an essential 
part in the states of excitement.. During the chronic course, 
on the contrary, there is said to be retention of phosphorus 
and nitrogen, and a loss of lime and sulphur. Rosenfeld 
invariably observed retention of nitrogen, 1-2 grm. daily. A 
considerable lowering of the need for oxygen which cannot 
be removed by thyroidin was shown by the researches of 
Bornstein. The restriction of the oxidation processes which 
is in healthy persons already noticeable between the 15th 
and 25th years undergoes here according to his investiga- 
tions a morbid increase. Grafe^ also found in catatonic 
stupor a distinct slowing of metabolism, a lowering of heat 
production to 39 per cent, of the normal, the increase of 
oxidation after the intake of nourishment showed a slower 
development. In the urine of the patients, sugar is occasion- 
ally found ; it probably is always a case of alimentary 
glycosuria, which could be fairly frequently demonstrated. 
Lugiato found retarded excretion of injected la:vulose. The 
elimination of methylene blue and iodide of potassium began 

' Dide et Chenais, Annates nK^dico-psychologiques 1902, 2, 406. 
- Pighini, Kivista sperimentale di frenia'.ria xxxiii, 566 ; d'Ormea e Maggiotto, 
Rifuima medica, 26, 1905. 

'•' Grafe, Deutsches Arohiv f. klin. Medizin, 102, 15. 



BODILY SYMPTOMS 



87 



according to the researches of d'Ormea and Maggiotto con- 
siderably later than in healthy persons and lasted longer. 
In the cerebro-spinal fluid Tighini found in 43 per cent, of 
his patients cholesterin which he never could demonstrate 
in healthy persons. 

In a series of cases I observed diffuse enlargements of the 
thyroid gland, occasionally the disappearance of such enlarge- 
ments immediately before the first appearance of morbid 
phenomena, also repeated rapid change in the size of the 
gland during the development of the malady. Occasionally 
exophthalmos and tremor were present. Lastly we noticed, 
as the relatives of the patients also did, not infrequently a 
turgid appearance and a thickening of the skin reminiscent 
of myxoedema, especially in the face. Unfortunately these 



tao 






X- 


J^^-r 


^^^^ ^ 


^-^T^K 


\ 


_ ., . +. , 



Fig. 21. — Body-weightin catatonic 
stupor with dementia. 



Fig. 22. — Body-weight in catatonic 
excitement. 



findings cannot be made use of further in the meantime 
because of the frequency of thyroid disease amongst us. 
Very frequently anaemic and chlorotic conditions appear to 
be present. 

Sleep and Food. — During the whole development of the 
disease the sleep of the patients is frequently disturbed even 
when they are lying quiet. The taking of food fluctuates 
from complete refusal to the greatest voracity. The body- 
weight usually falls at first often to a considerable degree, 
even to extreme emaciation, in spite of the most abundant 
nourishment. Later, on the contrary, we see the weight not 
infrequently rise quickly in the most extraordinary way, so 
that the patients in a short time acquire an uncommonly 
well-nourished turgid appearance. Sometimes, in quite short 
periods, very considerable differences in the body-weight are 



88 



DEMENTIA PR/ECOX 



noticed, probably in connection with fluctuations of the 
amount of water contained in the tissues. Of the curves 
which are here reproduced, Fig. 21, shows the body-weight in 
the usual course of a case of catatonic stupor termitiating 
in dementia of middle grade. Although after the awakening 
from stupor slight excitement set in, the weight increased 
very much. Fig, 22 was obtained from the patient whose 
temperature curve is given above, and who in spite of the 
most careful nursing and abundant nourishment sank in 
marasmus of the highest degree without any organic disease. 
Very great fluctuations of the body-weight, from the initial 
weight to the double of it, is shown in Fig. 23, which was 



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v\ 


/ 


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w 


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1 










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Fig. 23. — Bo()y-\vei{;ht in alternalion of stupor 1-ig. 24. — fluctuations in bo<iy- 

and excitement with dementia. weight in the beginning of a 

case of dementia priecox. 

obtained from a young catatonic. The patient after an initial 
alternation of stupor and excitement came to us, recovered at 
first, but then sank with diminution of the body weight again 
into deep stupor, from which he awoke after some months to 
increase rapidly in weight to an extraordinary extent ; but at 
the same time the transition to depressive dementia with 
some features of silly affectation had taken place. Lastly, 
Fig. 24 shows in a commencing dementia pra^cox a series of 
fairly regular fluctuations which kept pace with an alternation 
of stupor and greater clearness. Later this regularity ceased, 
and it came to permament dementia. 



CHAPTER V. 
CLINICAL FORMS. 

The presentation of clinical details in the large domain 
of dementia praecox meets with considerable difficulties, 
because a delimitation of the different clinical pictures can 
only be accomplished artificially. There is certainly a whole 
series of phases which frequently return, but between them 
there are such numerous transitions that in spite of all efforts 
it appears impossible at present to delimit them sharply and 
to assign each case without objection to a definite form. We 
shall be obliged therefore, as in paralysis, to content ourselves 
at first for the sake of a more lucid presentation with describ- 
ing the course of certain more frequent forms ' of the malady 
without attributing special clinical value to this grouping. 

As such forms I have hitherto separated from each other 
a hebephrenic, a catatonic, and a paranoid group of cases. 
This classification has been frequently accepted with many 
modifications, specially concerned with the clinical position 
of the paranoid diseases, as also by Bleuler in his monograph 
on schizophrenia ; he adds, however, to it the insidious 
"dementia simplex" as a special form. Racke has made 
other attempts at classification ; he separates out "depressive," 
" confused excited," " stuporous," " subacute paranoid " forms 
and a " catatonia in attacks." Wieg-Wickenthal differentiates 
"dementia simplex," "hebephrenia" with pseudomanic 
behaviour, " depressive paranoid forms " and catatonia. 

The undoubted inadequacy of my former classification 
has led me once more to undertake the attempt to make a 
more natural grouping, as I have in hand a larger number of 
possibly more reliable cases. For this purpose there were at 
my disposal about 500 cases in Heidelberg which had been 
investigated by myself, in which according to their clinical 
features, as well as according to the length of the time that 
had passed, the ultimate issue of the morbid process could be 
accepted with considerable probability. " Recovered " cases 
were not taken into account because of the uncertainty of 
their significance which still exists, but only such cases as 

' Sante de Sanctis, Rivista sperimentale de freniatria, xxxii, 141. 



90 DEMENTIA VRMCOX 

had led to profound dementia or to distinctly marked and 
permanent phenomena of decreased function. On grounds 
which will be discussed later, it is, as I believe, not to be 
assumed that by this choice definite clinical types have 
quite fallen out of the scope of our consideration ; at most a 
certain displacement in the frequency of the individual forms 
would be conceivable. 

The result of this attempt at a classification agrees in 
many points with the statements of the above-mentioned 
investigators. First I also think that I should delimit simple 
insidious dementia as a special clinical form. Next in the 
series comes hebephrenia in the narrower sense of silly 
dementia which was first described by Hecker. A third 
group is composed of the simple depressive or stuporous 
forms, a fourth of states of depression with delusions. In a 
fifth form I have brought together the majority of the clinical 
cases which go along with conditions of greater excite- 
ment ; one could speak of an agitated dementia praecox. To 
it is nearly related the sixth form, which includes essentially 
the catatonia of Kahlbaum, in which peculiar states of 
excitement are connected with stupor. A more divergent 
picture is seen in the seventh and eighth groups, in which the 
' cases are placed which run a paranoid course, according to 
whether they end in the usual terminal states of dementia 
praecox or in paranoid, relatively hallucinatory, weakminded- 
ness. We shall then subject to special consideration the 
small number of observations, which present the remarkable 
phenomenon of confusion of speech along with perfect sense 
and fairly reasonable activity. 

Dementia Simplex. 

Simple insidious dementia as it was described by Diem ^ 
under the name dementia simplex, consists in an impoverish- 
ment and devastation of the luhole psychic life which is 
accomplisJud quite imperceptibly. The disease begins usually 
in the years of sexual development, but often the first 
slight beginnings can be traced back into childhood. On 
the other hand Pick has also described a " primary progressive 
dementia of adults," but it is certainly very doubtful whether 
it may be grouped with dementia prc-ecox. In our patients 
a deterioration of mental activity becomes very gradually 
noticeable. The former good, perhaps distinguished, scholar 
fails always more conspicuously in tasks which till then 
he could carry out quite easily, and he is more and 

' Diem, Archiv f. Psychiatric xxxvii. in. 



CLINICAL FORMS 91 

more outstripped by his companions. He appears absent- 
minded, thoughtless, makes incomprehensible mistakes, cannot 
any longer follow the teaching rightly, does not reach the 
standard of the class. While pure exercises of memory are 
perhaps still satisfactory, a certain poverty of thought, 
weakness of judgment and incoherence in the train of ideas 
appears always more distinctly. Many patients try by 
redoubled efforts to compensate for the results of their 
mental falling off, which is at first attributed by parents 
and teachers to laziness and want of good will. They sit 
the whole day over their work, learn by heart with all their 
might, sit up late at night, without being able to make their 
work any better. Others become idle and indifferent, stare 
for hours at their books without reading, give themselves no 
trouble with their tasks, and are not incited either by kindness 
or severity. 

Hand in hand with this decline of mental activity there 
is a change of temperament, which often forms the first 
conspicuous sign of the developing malady. The patients 
become depressed, timid, lachrymose, or impertinent, irritable, 
malicious ; sometimes a certain obstinate stubbornness is 
developed. The circle of their interests becomes narrower ; 
their relations to their companions become cold ; they show 
neither attachment nor sympathy. Not infrequently a 
growing estrangement towards parents and brothers and 
sisters becomes noticeable. The patients remain indifferent 
to whatever happens in the family circle, shut themselves up, 
limit the contact with their relatives to the least possible. 
Bleuler brings forward here as a frequent explanation the 
" (Edipus complex," the concealed sexual inclination to one 
of the parents and the jealous emotions which arise from it. 
I consider that the generalization of that kind of case, which 
is certainly very rare, as belonging to the system of Freud, 
is wholly without foundation. It seems much more natural 
to me to explain the antagonism to relatives by the gloomy 
feeling of inferiority and the defiant resistance to it, but 
above all by the common experience that for a long time it 
has been the habit of the relatives to trace the morbid 
phenomena back to a moral offence, and to meet them with 
painful reprimands and measures. Similar antagonism is 
also seen quite commonly to develop in the relations with 
degenerate, wayward children. 

Ambition and pleasure in the usual games and occasional 
occupations become extinct; wishes and plans for the future 
are silent ; inclination and ability for useful occupation 
disappear. The patient has neither endurance nor under- 



92 DEMENTIA PR/ECOX 

standing, works confusedly, begins everything the wrong way 
about, triesas far as possible to withdraw himself from claims 
on him. He remains lying in bed for days, sits about 
anywhere, trifles away his time in occupations of no value, 
devours perhaps without choice and without understanding 
chance and unsuitable literature, lives one day at a time 
without a plan. A few patients have indeed at times a 
certain feeling of the change, which takes place in them, often 
in hypochondriacal colouring ; but the majority sink into 
dulness without being in any way sensible of it. Sometimes 
a certain restlessness is shown which causes the patient to 
take extended walks, to run away without an)- plan, to 
undertake aimless journeys. Alcohol is for him a special 
danger, he gives way to its temptations without resistance, 
and then very rapidly comes down in the world, and comes 
into conflict with public order and criminal law. That 
happens the more easily as many patients are very sensitive 
to intoxicating drinks. 

In these circumstances the inability of the patients to 
undergo the preparatory training or to attain to the calling 
which was planned for him becomes always more clear. He 
passes no more examinations, is sent away as useless from 
every apprenticeship, does not fit in anywhere, nor does he 
feel at home in anything. After all possible unsuccessful 
attempts to get them settled, many patients in the end 
remain idle at home, where they either lead a quiet existence 
without activity and without desire, without any disorder of 
note, or they live their own lives, and as capricious oddities 
try the patience of their relatives severely. Other patients 
succeed in getting a foothold in some subordinate calling, 
especially in gardening and agriculture, where in narrow 
surroundings they are in a position to fulfil a limited number 
of duties. Others again, as no other expedient is known, arc 
provided with some money and sent to America, where they 
immediately go to the bad ; some manage to enter the 
Foreign Legion and are there again turned away after severe 
discipline and punishment. A considerable number in the 
end fall into the crowd of beggars and vagabonds, and 
oscillate hither and thither in a half-witted state from year's 
end to year's end between public highway and workhouse, 
where ever anew the hopeless attempt is made " to turn them 
into useful people again." 

The development of this clinical picture invariably takes 
a series of years. It may stand still for a shorter or longer 
time, but on the other hand it may occasionally experience a 
more sudden exacerbation. The terminal result to which the 



CLINICAL FORMS 93 

malady leads is of varied character, as it may make a final 
halt on each step of its development. Thus then we see in 
a series of cases a very slight loss in the psychic life remain, 
which only becomes noticeable by comparison with former 
behaviour, while in others a marked psychic decline comes 
into existence. 

The frequency of the malady is probably fairly large, even 
if only a small number of the cases are considered as morbid 
at all or even fall into the hands of the alienist. Who cannot 
call to mind companions of his youth who at first gave just 
ground for certain, perhaps brilliant, hopes, but then from 
some point of their development onwards failed in an incom- 
prehensible way ? It is here a question of these young people 
who, without palpable cause and without any special morbid 
phenomena, simply trifle away the time, or are only able to 
gain a position in life far under their original prospects. 
Neither they nor their relatives have perhaps any idea 
that a morbid process has taken place; only the knowledge 
of cases which run a severer course, suggests the thought 
that such slight losses in psychic ability might also be 
due to dementia prsecox. Here and there, perhaps, also 
individual caprices, peculiarities or temperamental inadequacy 
in people who are otherwise well developed psychically 
are to be regarded as residua of slight morbid disorders 
of the same kind as the disease here discussed, if it can 
be proved that they were first developed in a definite period 
of life. 

When the disease comes to a standstill, it may mean a 
final, though incomplete, recovery ; but sooner or later the 
morbid process may again progress. We are not able at 
present to say whether the latter is always possible, or if in 
many cases it is excluded. A really profound dementia, 
without fairly acute exacerbations, with a continuous develop- 
ment of the malady, only slowly progressive, does not seem 
to occur. On the contrary, a dementia simplex which lasts 
for many years, even for decades, forms often enough the 
introduction to one of the forms of dementia prsecox which 
goes on to profound dementia, and which will be discussed 
later on. If one will, one may also regard dementia simplex 
in a certain way as the first period of dementia praecox. The 
cases which belong to it halt on one of the steps which form 
this period, while in the remaining forms there occurs pro- 
gress of the malady beyond that point. But a first period 
in the sense of the term dementia simplex can certainly not 
always be proved, except in a certain number of observed 
cases. 



94 DEMENTIA PRyECOX 

SiLLv Dementia. 

That form of dementia pra;cox which we have called 
above " silly dementia," is in many respects nearly related 
to simple insidious dementia. In its clinical picture there 
appears besides the progressive devastation of the psychic 
life incoherence in thinking, feeling, and action. It corre- 
sponds, as already mentioned, in its principal features to 
the clinical picture of hebephrenia which was described by 
Hecker ' in 1871 as a type in connection with the researches 
of Kahlbaum. Hecker at that time brought together under 
this term a group of cases in which, after an introductory 
stage of melancholy, a stage of mania develops and then 
rapidly makes room for a quite peculiar weak-minded con- 
dition. Daraszkiewicz ' then enlarged the idea of hebephrenia 
by including also the "depressed forms" which lead to pro- 
found insanity. 

The development of the disease is accomplished in almost 
four-fifths of the cases quite gradually; often an insidious 
change of the psychic personality precedes the appearance of 
more distinct morbid phenomena by many years. In the 
remaining patients the disorder begins in subacute form ; in 
a few cases it breaks out suddenly. In the preliminary stage 
there are sometimes nervous troubles, complaints of lassitude, 
headaches, feeling of giddiness, fainting-fits, irritability, dis- 
orders of sleep. The patients become absent-minded, forget- 
ful, negligent ; they tire easily, they cannot collect their 
thoughts any more ; they appear lacking in ideas and under- 
standing, they are silly and lazy ; they fail in daily tasks, 
change their occupation, because it is too difficult for them, 
set aside their work, or give it up entirely. 

Here and there hallucinations appear. The patients see 
apparitions, witches, dead people, will-o'-the-wisps, the devil 
with a white beard, little black mannikins, which sit down on 
their breasts. A patient saw " the three most beautiful crowns 
in the world"; "black points were flung at" another. They 
hear good or evil spirits, the Edison phonograph speaking, 
voices " talking always of love"; things are spoken into their 
head ; their thoughts become loud, their suspenders turn into 
snakes; their food appears green from arsenic; it smells of 
the water-closet. 

Delusions. — Not infrequently passing states of depres- 
sion are developed. The patients are dispirited and dejected, 

' Hecker, Virchows Archiv Hi. 394. 

- Daraszkiewicz, Uber Hebephrenic, insbesonderc deren schwere Form. Diss. 
Dorpat, 1892. 



CLINICAL FORMS 95 

they think they are syphilitic, have got the itch or dyspepsia ; 
they have a feeHng of oppression in their brain ; they search 
out all possible physicians and quacks ; the disease is in all 
their limbs. Their morbid sensations sometimes assume the 
most nonsensical forms. They have no brain any longer ; 
their back is broken in two ; their blood has been taken from 
them ; their body has died ; their legs are exchanged. A 
female patient thought that she had the Kaiser in her 
stomach, every human being in her body, a telephone, small 
dolls, a bicycle in her head, that she had a wooden head ; 
five people had been made out of her. Other patients become 
anxious, are to blame for everything, are damned, have com- 
mitted sins, are said to have killed someone ; they wish to 
make confession, read the Bible zealously, search out clerg)'- 
men. People are looking at them, speaking about them, 
making fun of them, hatching out abominable crimes, are 
persecuting them, are selling them for immoral purposes, are 
hypnotising them, are making fools of them. Little girls 
make sexual assaults on them ; everywhere there are enemies, 
" enchanters," conspirators ; it is a year of revolution, a 
hereditary feud ; the arch-enemy has a hand in it. Stuff is 
blown into the spinal marrow of the patient ; his nature is 
electrically withdrawn from him ; his forehead is bent in ; 
people blow up his testicles, cut his boots to pieces, give him 
poison in his food, assault him at night, mutilate him ; he 
gets a headache if he enters a church. He must be slaughtered, 
he is taken prisoner, stamped to pieces, " sawn asunder and 
broken on the wheel." His wife is unfaithful, has secret 
intercourse with two other men, wishes to poison him. 
Thoughts of suicide often rise to the surface ; a patient 
thought he would have liked to kill his child in order that 
it might not be so unhappy as himself. 

Exalted Ideas. — On the other hand we meet also, but in 
smaller range with exalted ideas. The patient feels that he 
has a special call, is something more than everyone else, has a 
proud spirit, an enormous will-power, is "the ornament of his 
feelings," is sent from God, will be Christ, receives revelations ; 
the feast of the atonement is there. He is Maurice Monfort 
of Scotland, is surrounded with princes and emperors, is des- 
cended from his grandfather Billbull, has 10-20,000 marks 
capital, will be a rich man ; the hospital belongs to him. He 
will attain to great things, will make a fortune by national 
bankruptcy ; he will have permission given him to carry on a 
temperance restaurant, and then he will dispense wine, beer, 
and brandy. A patient hoped to become "a general with 
250 marks yearly income"; a female patient thought that she 



96 DEMENTIA PRECOX 

was divorced and had children by a captain in the army ; 
another declared that she was the Empress Augusta. Many 
patients do not acknowledge their father any longer, they 
speak of their " so-called parents." 

At the time the patients are giving utterance to these 
nonsensical delusions they are for the most part fairly quiet 
and quite sensible, clear about time and place, about their 
surroundings and their affairs, but incoherent and desultory 
in their train of ideas ; they are not in a position to occupy 
themselves seriously and with perseverance in mental work ; 
they are childishly incapable of making a decision and 
susceptible to influence. Their delusions even appear mostly 
only as sudden thoughts, which are not further worked up or 
retained. Memory, especially what was learned at school, 
and the recollection of recent events may be quite undisturbed. 

Emotions. — These are for the most part in harmony with 
the ideas to which the patients give utterance, but are not 
very deep and they show quite sudden fluctuations. The 
patients laugh and weep without recognisable cause, some- 
times convulsively, fall abruptly into violent excitement, but 
quieten down again just as suddenly. Sometimes there pre- 
dominates an imperturbably exalted, self-satisfied mood ; in 
other patients, a childish hilarity which passes easily into a 
lachrymose state or a pitiable faint-heartedness ; or the 
patients are mistrustful, peevish, impertinent, rough and rude, 
break out into obscene abuse on the most insignificant 
occasions, threaten and become violent. A patient without 
more ado shot a railway employee with whom he had fallen 
into an altercation. A few patients incline to exaggerated 
leligiosity ; a patient wished to change his religion ; others 
plan to go into a cloister. Many are sexually excited, plan to 
be married ; show a " pathetic desire for love," masturbate, 
expose themselves, make sexual assaults on little girls ; a 
patient wished to go to bed with his mother and sister. 
Women put matrimonial advertisements into the newspapers, 
" scream for a husband," give themselves without regard to 
anyone, let whole troops of young men on the highway misuse 
them, and fall into prostitution. 

Conduct- — The disease makes itself noticeable in by far 
the most striking way in the activities of the patients. Already 
in the beginning of the rnalady a change in their behaviour 
invariably sets in. They become dreamy, shy of their fellow- 
beings, withdraw themselves, shut themselves up, do not 
greet their friends any more, stand about in corners, stare 
intently in front of them, give no answer, talk with themselves. 
Others become stubborn, self-willed, difficult, insubordinate, or 



CLINICAL FORMS 97 

unrestrained, restless, loquacious. Their capacity for work 
suffers severely. They do not trouble themselves any more 
about their obligations, do everything the wrong way about ; 
a patient cleaned his boots with mud. They leave everything 
where it is, suddenly throw the shovel away, go to bed, look 
out at the window all day long, busy themselves with trifling 
affairs, make wreaths of flowers ; they exert themselves to 
learn poems off by heart, or to begin Latin ; a patient said 
" he took as great pains as possible to investigate thoroughly 
what the real meaning of positive and negative electricity 
was." Many patients stop working, because they have enough 
to live on ; others l^ecause of their performances being of less 
value, work " for board " without wages ; they frequently 
chafige their situations because they are of no use anywhere. 
One of my patients suddenly appeared unasked at the house 
of strangers with a stolen manure-fork in order to spread 
manure ; another time when he'again escaped he joined some 
workmen and unloaded stones with them, then went to a 
strange stable and began there to saw wood. A few patients 
have in view to change their occupation. A patient who till 
then had wished to study theology, decided to study 
medicine because theology was ^ too stupid " for him, another 
planned to go on the stage, a third who had never shown 
any musical inclinations wished to . study the theory of 
music ; a fourth patient wished for himself " a little post in 
the hospital." 

The whole conduct of life of the patients becomes senseless 
and incoherent. They cannot any longer manage money ; 
they make aimless purchases, give away and squander their 
property ; a female patient threw good fruit to the pigs. A 
poor patient fooled away an inheritance of 5000 marks 
within two years; another stopped taking money for the 
wares which he sold. Many patients fall into drinking 
habits and in this way come down in the world with remark- 
able rapidity. In their outer appearance they become dis- 
orderly, negligent, dirty, peculiar. They do not wash them- 
selves any more ; they wear conspicuous clothing, tie cigar 
ribbons in their button-hole, stick paper in their ears ; a 
patient put on a truss without any reason ; a lawyer bound 
flowers on to his stick and umbrella, hung a garland round 
his neck, stuck brooches and pictures on himself, blackened 
his face, painted a large paragraph sign on his coat. 

With these are associated a multitude of incomprehensible 
and childishly aimless actions. The patients throw stones, 
lie down in cruciform attitude on the floor, cut off their hair, 
undress, bathe publicly in the middle of the town, begin to 

G 



98 DEMENTIA PR/ECOX 

play the harmonica at night, run a&out on the rails of the 
shunting-station, burn their own hair and beard and those of 
other people with their cigar, cut up their linen and clothing ; 
they destroy the furniture and throw it about ; they lie 
sprawling on the floor, turn somersaults in bed, climb on to 
the stove, slide about the room with chairs. A patient 
smashed a crucifix and a gravestone ; a second tolled the 
big bell during divine service ; a third lit the candles on the 
high altar and imitated the clergyman, a fourth lay down in 
a fountain. A teacher played tag with his scholars, lay 
down in a crib in the cow-house " from love of mischief," 
put his head into the well, because on account of his great 
sins he could do very well with another baptism, lay down 
on the floor in order to measure how long his coffin wt)uld 
have to be ; a lady fed her dolls with coffee. A female 
patient abused herself grossly with the strongest expressions, 
others try to throttle themselves, to cut their throat, to cut 
off" their fingers, usually without special energy, often in full 
publicity. A patient asked for gunpowder ; another scratched 
himself with his knife in order to lessen the influences ; a 
female patient wished that her body should be cut up. 

Very frequently we observe ifi the patients a certain 
restlessness. They run away suddenly from their work, 
roam about, wade barefoot in the snow,- insist on going 
out even at night, become deserters, hide themselves away, 
make senseless journeys, often without money and without 
a ticket, want to get into the Castle, to go to America ; a 
patient wandered for days in the forest without food. In 
-consequence of this they easily become vagrants, beg, commit 
small thefts, and land in this way in prison and the work- 
house, where then a deterioration of their condition often sets 
in ; nearly a quarter of my male patients met this fate. 

The conduct of the patients invariably shows many 
peculiarities. They are very changeable in their behaviour, 
sometimes accessible, childlike, docile, at other times repellent, 
inapproachable, resistive, irritable, flaring up easily, at One 
moment loquacious and verbose, at another taciturn and 
mute. Their mode of speech is frequently manneristic, 
unctuous, didactic, sometimes noisy or purposely obscene. 
The substance of their conversation is often confused and 
unintelligible, or there is nothing in it. Frequently they ride 
to death certain phrases ; they indulge in stale jokes and 
insipid doggerel ; they introduce unusual or foreign expres- 
sions or dialect. Many patients startle us by extraordinary 
turns of expression and abrupt nonsensical questions ; a 
patient said, " He blows his nose, and I blow mine ; who 



CLINICAL FORMS 99 

then is right, I or he ? " Others have a tendency to foolish 
plays on words and to, peculiar symbolism. 

Writing. — These peculiarities often appear more distinctly 
in the writing of the patients which are usually in " Karlchen- 
Miesnik-style," according to Hecker's description. Besides 
negligent want of connection in the train of thought, repeated 
change of construction in long spun-out periods^ mixed 
metaphors^ abrupt interspersing of sudden ideas, rhymed 
effusions, we find a slovenly external form, irregular hand- 
writing, flourishes on single letters, underlining, deficiency or 
superfluity in marks of punctuation, and monotonous contents 
often with verbal repetitions. An example is given in 
the following extract from a letter written by a student who 
was up for his leaving examinations. The extract forms 
the introduction to the specimen of writing 4 which -is 
reproduced here -.— 

"When you on the 19th May of this year, namely on a beautiful Sunday 
afternoon, constructed the plan for yourself to do nie the honour to visit 
me by the railway in the Hospital for the Insane at H., care of Professor 
K., Littera Voss-strasse Nr 4, you thought then perhaps to give your dear 
and good son a special pleasure, visiting him in the institution I — Or was 
it not so? I — When I further recapitulate again the many unjust things 
and abusive epithets which I threw at the head of my dear mama, I 
think that I really cannot avoid being obliged to confess that I should 
have rather expected a visit first from the maternal side. Supposing 
namely the case that the above mentioned should not only have been ill, 
but had actually been so, so would my humble self have first strongly 
advised in her case a visit to her first-born ! Now as happily my 
22nd birthday coincided with Ascension day, as God and fate would 
have it, but in the Asylum, the visit of my mother in person certainly 
caused me a great momentary joy, especially as she from motherly 
love showed me the honour and kindness to promise to bring me another 
cake and a silver chain, but in any case her visit would not and could not 
be a visible comfort for me for the old reason, namely my father's 
dissatisfaction with my diligence at home, regarding conscientiousness ! 
Further I thank you also most heartily for the beautiful artistic card with 
the special signature Family G. But wait ! Who should the Family G. 
be then in this case, if its principal member is crouching in a madhouse ? " 
and so on. 

The shallowness of the contents, the incomprehensibility, 
the laboured style, the incoherence of the train of thought, as 
well as the slovenly external form, which is scarcely decipher- 
able on account of the many crossings-out and alterations, all 
these features of the specimen of writing appended here show 
the profound mental incapacity, which is in sharp contra- 
diction to the cultural standing of the patient who was 
originally highly gifted. For comparison, I place beside it 
a letter very similar as regards -handwriting, written by a 
day-labourer likewise hebephrenic. The letter is better 



lOO 



DEMKNTIA PRECOX 







//J «/^ 



-t-'^tA^i 






/!• 











S-^T^^x^ 



r 



'..^ 






^*^ ^C^A^f-v^ _ ^y^^/l^i^i^^ ^'•^'Jfl/^^V^^^-iv^^tt-^^^-t^**^ 



^«'^€?/,i^ *t>-t-'i^ < 



/a 







Specimen of writing 4. Letter of » Hebephrenic. 



CLINICAL FORMS loi 

arranged in external form, but the contents are still .more 
incoherent. The abrupt breaking- off of the ideas, the 
vacuity of thought, the meaningless expressions of speech 
are accompanied here by a certain feeling of disease : — 

"Dear parents and brothers and sisters, Do not be anxious about me, 
my thoughts are directed in the right way, I hope you will not experience 
that again. I am convinced that you meant well with me and still 
mean well. Social relations make it necessary to pay taxes. To live 
and let live is the main principle of the purely human thought especially 
of a day-labourer as I am. The arrival has done me good ; but I am 
somewhat weak in my nerves. I shall take pains to direct my thoughts 
wholly according to the nat. liberal circumstances, not socialist. I am 
also no longer so melancholy, have lost m knowledge terribly. 

In the following extract from a letter of a young business 
man the feeling of disease also appears distinctly along with 
the peculiarity of expression : — 

"There is no prospect that an after-eflfect event, of my symptoms 
come to a decision, but it is certain that the contained sensations unfold 
their arrangement. ... As regards my condition, end-symptoms of 
epileptic combination show themselves and I am always prepared, if that 
should come, which I did not expect. The depressive phenomena 
corresponding to subj. psych, neurasthenic combination are of a 
permanent kind and now you will perhaps yourself know what is 
impending. . . . With my psychological and psychiatric studies also will 
it now soon be done, for my condition is itself composed of psychiatry 

Another patient, who afterwards became drivellingly 
demented, wrote to a married woman in a lengthy document 
from the " madhouse H." a declaration of love in German, 
English, French, and Greek with the assurance, that he had 
to .get air for his oppressed heart, and must explain what he 
could not keep any longer for himself alone without being 
obliged to fear that he would get palpitation or that his 
senses would take a different direction from that which 
nature had traced out for them. A young student of 
divinity composed the following poem, in which the vacuity 
of the jingle of words as well as the loss of artistic feeling 
comes very clearly to expression : — 

Ferner Lander Stadte hab' ich viel gesehen, 
, Wunderbar gebaut und riesengross, 

Und es herrschte drin ein eigenartig Wehen, 

Barg manch' siiss Geheimnis in dem Schoss. 

Und die Ratsel blieben ungeldst, 

Hatte nicht die Liebste heimlich mir verraten, 

Was uns anzieht, was uns von sich stosst, 

Und dies alles bei dem besten Wein und Braten. 

The bearmg of the patients is often constrained, forced, 
affected, or slack and negligent, "not military," as was 



I02 DEMENTIA PRECOX 

ascertained in the case of a soldier; they frequently also 
commit breaches of military discipline, laugh in the ranks, 
do not stand erect. They make faces, assume peculiar 
attitudes, lie on their faces, make strange gestures, scratch 
themselves till the blood comes, spit, are occasionally filthy, 
produce nonsensical drawings and needlework. Not 
infrequently automatic obedience, especially catalepsy, can 
be demonstrated. 

The sleep of the patients is frequently disturbed, some- 
times by excitement at night. The appetite is irregular ; the 
patients are sometimes voracious; at other times they eat 
nothing or only certain articles of food, cram them hastily 
into their mouth, eat in an extremely unmannerly way, 
seize the food with their hands. A patient declined food, 
giving as his motive that he lived on the supernatural ; 
another asked for better food and at the same time called 
out : " Waiter, a glass of water ! " 

The Further Course of the disease in the very great 
majority of cases which I have brought together led to 
profound dementia in which for the most part the peculiarities 
of the previous morbid condition, silly conduct and in- 
coherence of the train of thought, were still distinctly 
recognisable. In a quarter of the cases the patients became 
wholly dull and devoid of thought, in a further number ot 
cases manneristic or negativistic. Only in about 12 per cent, 
of the observed cases the disorders disappeared so far that a 
simple weak-mindedness remained without other striking 
morbid phenomena. Improvement lasting somewhat longer, 
8 or 10 years, with later relapse, was ascertained in about 
7 per cent, of the cases. Not infrequently the condition 
exhibited fluctuations, sometimes within a fairly regular 
return, it may be in connection with the menses. As the 
issue in states of slight weakness was noted in about 19 per 
cent, of the total number of our cases of dementia praecox, 
and considerable and more lasting improvement occurred in 
nearly 26 per cent, of the cases, we must regard silly dementia 
as an unfavourable form of the disease. It includes about 
13 per cent, of our observed cases. Seizures, in nearly 21 per 
cent., appear to be a little more frequent than in the average. 
The age of the patient corresponds fairly accurately with 
that of dementia praecox as a whole ; 59 per cent, of the 
patients had not yet reached their 25th year ; the male sex 
was represented by 63 per cent., which is considerably more 
than the average (56 per cent.) 



CLINICAL FORMS .103 

Simple Depressive Dementia. 

As the third group of dementia praecox I should like to 
take together under the name of simple depressive or 
stuporous dementia, those cases in which after an introductory 
state of depression with or without phenomena of stupor a 
definite psychic decline gradually develops. The beginning 
of the disease is in something more than half of the cases 
slowly progressive; still in nearly 20 per cent, it is acute, 
especially in the forms in which there is stupor. Sometimes 
for a number of years before the actual onset of the disease 
there is a history of a quiet, shy, depressed behaviour. The 
introductory phenomena are those already described — head- 
aches, vertigo, disorders of sleep, failing appetite, great need 
for rest, now and then fainting fits, hysteriforrh or epileptiform 
seizures. The patients stop working, neglect the household, 
go to bed, withdraw themselves, stare into a hole, are 
continually brooding, run away, hide themselves, carry on 
confused conversations. 

Hallucinations. — Not infrequently hallucinations appear, 
although they do not usually take up much room in the 
clinical picture. The patients see the Virgin Mary on the 
ceiling, heavenly apparitions, God and the devil, mice ; they 
hear people gossiping, spirits making a noise, the voice of 
their father or of their neighbour, of the " men from the 
churchyard," of the "tormentors from above downwards," of 
the maidens ; their companions are jeering. Reproaches are 
made to them and commands bestowed on them, thoughts 
are given to them which must be repeated. " The voices 
work the system of thought and breath," said a female 
patient ; she heard that she was damned, that she was no 
longer pure, that she was to be hacked to pieces. To other 
patients eating is forbidden; "that has crept in so for the 
last five or six years," said a patient. The feeling of sexual 
or hypnotic influence also occurs. 

Depression. — As a rule all sorts of depressive ideas 
appear on the surface, especially those of hypochondriacal 
content. . The patient suffers from all possible diseases, from 
softening of the brain, is weak in his head, ill in his nerves, 
has foul blood, has contracted atrophy of the nerves by 
onanism, has lost his reason ; one half of his body is already 
gone ; he never has his life. His sense is torn asunder, his 
body is melted up, his heart is worn out ; " reason, under- 
standing, cind sense have gone out of my brain," said a female 
patient; another asserted that he had "the half exhalation 
of a woman." The following extracts from a comprehensive 



I04 DEMENTIA PRECOX 

description of himself written by a patient who was perma- 
nently quite sensible and reasonable, may give an idea of 
these hypochondriacal trains of thought which gradually 
develop alongside of the most various hallucinations and 
dysaesthesict : — 

"Already in June very great excitement became noticeable in me. 
. . . Remarks about me could excite me in the highest degree. In 
studying I began sometimes at one place, sometimes at another . . . ; in 
writing I then very often made mistakes, i . . All at once it happened to 
ine that studying was no longer at all possible ; the sentence that had 
been read shortly before did not slick.- In a rather long excerpt, which 
I had already begun, I noticed a considerable change in my handwriting, 
and that the handwriting changed in the course of the copying of a few 
pages. I carried on my studies in a most extraordinary hurried way, 
and did not allow myself any more the necessary rest and recreation ; I 
was unwilling to take any more the necessary time even for eating. . . . My 
memory left much to be desired already for a considerable time. . . . My 
sleep was bad ; I could not fall asleep for a long time, and in the morn- 
ing I was not properly strengthened and refreshed. . . . Physically I 
became gradually weaker ; the skin of my face became pale and was 
pasty to the touch. I constantly had the inclination to look in the mirror. 
I saw that my eyes had a peculiarly dull lustre. If I turned my head 
quickly, immediately a peculiar cracking was heard. I was struck by 
the rapid diminution of my visual power, in spite of the fact that I spared 
my eyes. ... I had accustomed myself for a long time when I went a 
walk to wend my steps where I had the prospect of meeting only a few 
people. ... I ^\d not trust myself any longer to look at people. . . . 
Later I then began to have a certain fear of everything ; I did not trust 
myself any longer to look at anything, and thought that enjoyment, of 
nature was also forbidden to me ; ideas, as if I dared not any more 
touch myself or look at myself, came to me occasionally. When I then, 
under- medical treatment, took bromides, I got curious pricking sensa- 
tions in my brain. In walking I thought that the right leg was thrown 
out in front of me, sometimes also the left leg. . . . Till sleep came over 
me I had a sensation in my legs as if they were squeezed firmly and as if 
the skin were contracted on the shin bones and feet. On the left side 
of the body I thought a paint brush was being stroked downwards, 
especially in the region of the heart. Often till I fell asleep I could not 
get enough breath ; I had the feeling as if it always drove the belly 
higher up, and as if there were an impediment against the breastbone in 
my breast, so that my breast could not sink any more. In my head I 
thought balls rolled up and then fell down. Besides that I had also the 
following sensations ; my skull-cup was like glass to the touch and my 
hair like fur ; my skull could be pressed together at will ; my head was 
sometimes light and sometimes heavy ; my teeth were sometimes 
knocked out, sometimes knocked in. My tongue was sometimes too 
long for speaking so that it came close against my teeth, sometimes it 
was too short and contracted. In my gums I was aware of all kinds of 
oppressive and dragging feelings ; my nose was sometimes knocked 
inwards, sometimes outwards. There was sometimes a bad smell of the 
mouth ; sometimes there was a fragrant odour. Often also such a smell 
was blown on me. Cold air was blown over my face. Someone sat 
down beside me on the bed. My buttocks were rough like a grater. 
There were noises in my heart, there was a rubbing as of two millstones 
on each other. Sometimes I felt my body light, sometimes heavy. I 



CLINICAL FORMS 105 

thought someone was sleeping close beside me and sometimes also over 
me. I heard loud hammering on the wall and whizzing in the air. The 
bedstead sank downwards at my feet and rose upwards at my head, or it 
turned over sidewards. I flew away, the bed with me. The voices were 
often preferable to these sensations ; I could more easily fall asleep with 
the former. I heard pilgrims pass by in two choruses ; the one said : 
'He must die,' or 'He is dying'; the other: 'He is becoming again.' 
First I heard the great bell ring, then small bells, then great and small 
•confusedly. When reading I was disturbed by a voice on my left which 
read quickly along with me in an unpleasant way. . . . The back of my 
head appeared to me, when I laid it on the pillow, all wobbling and soft. 
At and in my head I had the following sensations : — pricking above, 
squirting from my hair, the falling down of big drops out of my head on 
to the pillow. Besides that, I often thought that drops were falling on 
the bedcover or on the sleeve of my night-shirt, on the back of my hand, 
on my finger-nails. ... I saw people with two shadows in place of eyes, 
then blind : then again I thought they had scintillating fire in their eyes ; 
once only for a short time I saw people black in the face. ... I had a 
feeling as if a worm would creep around in my brain ; then would creep 
through my gums and tongue into my spinal marrow ; in my neck I felt 
crackling crashing noises. ... I heard the following voices : ' Nothing 
rare,' ' Nothing special,' ' Carrion,' ' Rascal,' ' Onanist,' and especially in 
the last part of the time nothing but my name." 

The patient who while suffering from the phenomena 
described was slowly becoming weak-minded, not only 
observed himself most accurately but . also recognised 
quite clearly the morbidity of the disorders reported by 
himself; the remarkable point in his case was only the 
equanimity with which he reproduced all his tormenting 
perceptions. 

Ideas of Sin and of Persecution. — Not infrequently ideas 
•of sin also appear, and in connection with them ideas of 
persecution. The patient has sworn falsely, committed a 
mortal sin, is a " sinful serpent," is accused of sodomy, wants 
to die. He must atone, be sacrificed, has fallen into the 
hands of the evil one who is now going to wring his neck. 
He is shut out from society, is afraid of an assault by night ; 
people are not kind to him. He is watched, is going to be 
fetched, is to be dragged away in the knacker's cart, is to 
be beheaded, is to be killed by a painful death. His food 
is filthy, contains poison. Often these ideas are very in- 
distinct and obscure and only find utterance on questioning. 
Here and there an exalted idea is also perhaps on an 
. occasion brought forward ; the patient is a substituted child, 
must strive after something higher, must meet with Kaiser 
and Kings, is in Paradise. The patient, from whom the 
above description of himself came, thought some years later 
that he would quite likely yet become a professor. 

Perception usually exhibits at first no very serious 
disorders, yet the patients are for the most part inattentive. 



io6 DEMENTIA PRECOX 

indififerent, often also repellent, melancholy. People and 
surroundings are as a rule correctly recognised, while the 
patients are often not clear about time-relations. The train 
of thought of the patients changes abruptly, is at times 
confused, is easily diverted. Memory, acquired knowledge 
and expertness remain sometimes fairly well preserved, 
sometimes they undergo considerable loss. Soonei: or later, 
however, a certain mental decay makes itself felt ; the 
patients become poor in ideas and weak in judgment ; " I 
often don't know at all what is the matter with me," said a 
patient. The relatives of a female patient declared, " She 
couldn't think rightly and did not know what she was 
talking about." 

Mood is in the beginning usually anxious, dejected, 
lachrymose and despondent ; the patients have no more joy 
in life, are about to despair, do not trust themselves ; they 
weep and lament, would like to die because things do not 
please them any more. They frequently make attempts at 
suicide, often in very nonsensical ways. They try to throw 
themselves out at the window, dash their head against a 
wall, go into a stream to turn back again immediately, run 
into the forest to let themselves freeze to death there. A 
female patient drank petroleum ; a patient hung his head 
out of the bed in order that it could be hewn off. Some- 
times periods of exalted and even unrestrained mood 
temporarily intervene. Other patients are irritable, morose, 
violent. Sexual excitement vents itself in impulsive mas- 
turbation and in sexual intercourse regardless of consequences ; 
a patient made a proposal of marriage to a lady who was 
wholly unknown to him. In the further course, however, 
often very soon, the emotional life becomes duller \ the 
participation of the patients in the events around them 
becomes always feebler. They do not trouble themselves 
about their fellow-patients, remain indifferent to exciting 
events, do not move a muscle if one occupies himself with 
them or even causes them pain. At the same time they • 
become dirty, spit into the dishes used for food, smear 
themselves with urine, play with lumps of fneces, make 
messes. 

Volition. — In the whole conduct of the patients the 
devastation of their will makes itself conspicuous above 
everything. They are tired, weak, lazy, without initiative, 
irresolute, let themselves become destitute, live carelessly a 
day at a time, fling away money and pos.sessions senselessly, 
let themselves drift according to chance influences and there- 
fore come quickly down in the world especially when they 



CLINICAL FORMS io; 

begin to drink. Many become vagrants, as an elementary 
school-teacher did in my observation who gradually had 
•become unfit tor his calling. Occasionally the stupidity and 
irritability of the" patients lead to very risky actions. A 
female patient did not turn off the gas ; a patient threatened 
his wife with his knife ; another bought a revolver to defend 
himself. Many patients must be washed and dressed like 
children. Very frequently automatic obedience can be 
demonstrated in them. 

Besides this weakness of will there is often a certain 
restlessness; the patients change their calling and situation, 
run away, make aimless journeys ; a patient sailed three 
times to America and back. To that may be added all 
kinds of impulsive actions. The patients speak away to 
themselves, collect everything possible in their pockets, play 
the piano all day, scream suddenly for hours, force their 
way out howling, pray, sing, laugh uncontrollably, become 
violent without cause, slide about on the floor, climb up on 
to the windows. Stereotyped movements also occur, rhyth- 
mical movements of the body, odd movements of arm and 
finger, wringing of the hands, picking and pulling the fingers, 
running up and down. A patient always squeezed his 
urethra together; another squeezed his forearm continually 
with his fingers spread out. He gave the following account 
of the motives of his behaviour : — 

" I must do that ; if I do not lift it I have on the side no com- 
plete course, no inner life ; it is just bad since I had the congestion, 
the disturbance in the inner vascular passage. Sometimes I am out- 
wardly so animated, so emotional, sometimes again inwardly. My 
blood is always so unfaithful, my animation is, however, different, 
sometimes inward life, sometimes outward life ; I feel that so. I am 
just weak in my nerves, weak and weakened in my whole body ; I 
must do that ; otherwise I can't hold out. The drainage through the 
limbs must be there ; otherwise the constituent parts could not circulate 
through the pores, the blood, even the moisture. I will yet live ; I 
am yet a young being ; I itiust always look after the drainage. ..." 

The remaining volitional disorders of dementia praecox 
usually appear also in more or less pronounced fashion. 
Mannerisms show themselves in making faces, in whimsical 
ways of shaking hands, in stirring food about, in parade step 
in marching, in solemn and affected gestures, in rattling in 
the throat and smacking movements which are interpolated 
in conversation. Many patients lie on their belly, anywhere 
on the floor, on the edge of the bed, take up uncomfortable 
positions, keep the corner of the bedcover in their mouth. 
The conversation of tlje patients is incoherent, sprinkled 
with meaningless words, odd phrases, bewildering expressions. 



io8 DEMENTIA PRECOX 

A patient abruptly approached the physician and said : 
" Would ask you for the divine highness." Many patients 
lisp, whisper, speak in affected High German, speak Krench, 
scream with a disguised voice. Negativism meets us in the 
unapproachable, repellent behaviour of the patients. They 
do not return a greeting, do not look up when they are 
addressed, give evasive, nonsensical answers or even none 
at all, stop in the middle of a sentence, begin to speak when 
one turns away. They draw back when one approaches 
them, go backwards round the room, creep under the bed, 
resist obstinately every regulation. Their deportment is 
stiff, rigid, constrained ; their limbs become stiff at every 
interference ; many patients lie in bed with their heads 
lifted up, or sit with bowed heads and closed eyes. They 
do not remain in bed, endure no shirt, stand about naked, 
do not eat anything or only eat if they think they are 
unobserved ; many take greedily other people's food or only 
eat standing in a corner. 

These negativistic phenomena, united with and alternating 
with those of automatic obedience, characterise the states of 
stupor \s\{\c\\ develop in rather more than one-third of our cases. 
These states follow closely the introductory sad or anxious ill 
humour after a shorter or longer period, and may be of very 
various duration. Not infrequently they are interrupted by 
quickly passing states of excitement ; the patients suddenly 
sing a song, jump out of bed, have a fit of laughter. 

The number of cases brought together in this group 
amounts almost to lo per cent, of the cases worked up here. 
As 69 per cent, of the patients had not yet passed their 25th 
year, we have here to do with a form which by preference 
attacks young subjects. The male sex was represented by 
53 per cent, therefore differing little from the average, but it 
seemed to have a greater share in the cases in which stupor 
occurred. 

The further course of the disease was interrupted in 
something over 10 per cent, of the cases by improvement 
which sometimes continued for several years ; it appeared 
to me to be more frequent in the stuporous cases. In one 
female patient such improvement occurred four times ; re- 
lap.ses always of longer duration followed each time after 
childbirth till at last a state of dementia developed which 
lasted without change till death 5 years later. As issue there 
was in 27 per cent, of the cases a moderate weak-mindedness 
to be recorded ; the form which is considered here has there- 
fore a substantially more favourajple prognosis than silly 
dementia; seizures appeared in 17 per cent, somewhat 



CLINICAL FORMS 109 

seldomer than in the latter. Among the states of profound 
dementia forms with complete apathy or with negativistic 
features were the most frequent, the latter specially as 
termination of stupor. 

Delusional Depressive Dementia. 

Those cases, in which delusions gain a considerable 
expansion and an extraordinary form, we take together as a 
fourth form of dementia praecox, depressive dementia with 
delusions. The beginning of the disease is quite similar to 
that of the last group, but apparently somewhat more 
frequently sttbacute. Often after changes in the behaviour of 
the patients have already gone on for years, they become 
quiet, depressed, anxious, restless, complain of headaches, 
giddiness, sleeplessness, noises in the ear, and they leave off 
working ; a patient suffered for a considerable time from 
agoraphobia. 

Hallucinations. — Gradually or suddenly numerous 
hallucinations now make their appearance. The patients see 
"horrible pictures," naked females, three little men of the woods, 
long processions of decorated people, fiery beams, the Mother 
of God, " God, two lions and the Kaiser," figures in heaven ; 
angels and the Virgin Mary offer him the chalice. A female 
patient saw " her thoughts." 

Hallucinations of hearing are usually the most strongly 
marked. There is a noise in the house ; burglars are forcing 
their way in ; the children are wailing ; there is a noise of 
crashing and banging in the air. The patients hear scream- 
ing, " whizzing," " chatting in the ear," " frightful talking," 
" wholly peculiar matters," improper things ; " coarse and 
refined things " are said to them ; it is a " secret language " ; 
there are voices from heaven, beneath, voices with electric 
wires ; sometimes the whole body speaks. The voices 
torment them all day long, reproach them that they have 
lived an immoral life, that they have committed a moral 
offence on themselves, that they are wanted by the police. 
" That is the wickedest man of all " they say, " a bastard " ; he 
should have a sound thrashing, his ears should be cut off; he 
should be executed, slaughtered, he can make poison ; she 
has a child. On the other hand it is said to the patient that 
he is to get a uniform, is to become a policeman, is to marry. 
The voices question him, give him thoughts. His thoughts 
become loud, so that others know thenr, and he can com- 
municate with the whole world by telephone ; it is said to 
him that he cannot think. A female patient stated that she 



no . DEMENTIA PRECOX 

often felt as if she got something placed quite softly in her 
mind when she was thinking of nothing. Strange people, 
physicians, speak in the patient and he must speak after 
them, " confirmations to be spoken out in a low tone " ; his 
mother forbids him to eat; a voice calls upon him to 
slaughter his wife ; a female patient was directed to take off 
her clothes. 

Food has a peculiar taste, of petroleum, it contains 
"shoenail juice and potash"; it smells "of poison," of 
sulphur ; the patient is conscious of oil in his mouth, of the 
smell of powder, he is being chloroformed. Something 
comes against his face, he feels that he is being pricked all 
over, that his neck is being cut off, that sand is being spirted 
into his ears, that he is being electrified ; a female patient got 
prickings in her heart when anyone died. A few patients 
feel sensations in their body; others have the feeling "that 
gentlemen do wicked things to them," "so tickling things, 
which are not pretty." Often such sensations are interpreted 
in an extraordinary way ; a female patient noticed that the 
physician went backwards and forwards in her body ; a male 
patient felt that a man was fastened to him. 

An excellent idqa of the early development of the malady 
is 'afforded by the following extracts from the description 
written by the patient herself, a musician, who fell ill very 
acutely and quickly became weakminded. She wrote it five 
weeks after the beginning of the illness on her own 
initiative : — 

"In the following night I was electrified. I conclude that from the fact 
that the following morning I felt quite peculiar pains and twitchings, and 
it was called out to me a few days before by an electrical machine, which 
had inspired me with all possible moods and thoughts, and by means of 
which each thought is understood; 'We have electrified you' ... As 
a great criminal was conjectured in my person or even an anarchist (I), I 
was several times examined electrically on my conscience with the 
greatest pains. .Since that day I have had terrible stories of murder and 
theft in my head, which, as I know that the machine is still always 
working on me, can absolutely not be controlled. . . . Had I foreseen 
that I would be tormented so long, I should have noted down this quite 
remarkable torture already from the first day onwards ; now un- 
fortunately I can still remember only a little. I make notes of all this 
for myself because I am now fearfully unh.ippy. I feel that by the machine 
I am mentally always more irritated, and have already often asked that 
the current should be stopped and my natural thinking be given back to 
me, as otherwise within measurable time a catastrophe could easily 
occur. Moreover, it appeared to me as if papa and mama were also 
electrified in the first days, as I very distinctly recognised by the move- 
ments and by the expression of the face of my parents at my often 
dreadful thoughts. ... I must here mention another point which let me 
understand quite well that the machine was still working. This is that 
horrible smells from time to time, I don't know how, are transmitted to 



CLINICAL FORMS in 

me. When the physician examined me such plague smells also streamed 
out, that the doctor went backwards terrified. . . . One evening it was 
called out to me by the machine : ' We conjecture in you the murderer 
of the Empress of Austria (!!!)'... It was suggested to me by 
electrical means, that I wished to murder L. ; as I was for some time 
speechless about it, it was called out to me by the niachine : "You have 
brought great shame on yourself ... As on this I had to endure 
frightful pains — the electric current went as already before through my 
whole body — it was called out to me : ' You will now be lynched (I !) ' . . . 
In particular the last word (anarchist) was for several minutes formally 
wound round my head. . . . How my thoughts are all so exactly under- 
stood and whole sentences are thrown back to me by the machine — this 
is fact, that I know definitely that these for the greatest part are not 
my own thoughts — is a great riddle to me. This must be a very 
complicated machine, which has put me myself in any emotional mood 
whatever, as earnest, cheerful, laughing, crying, furious, humorous — at 
different limes it was also adjusted to grim humour, that I understood 
very well — amiable, morose, energetic, absent-minded (very frequently 
employed), attentive, dwelling of thoughts on one point to unconscious- 
ness, yes, even to madness — I remember one evening when I actually did 
not know what I was thinking — melancholy, confused and so on. The 
very remarkable machine is also able to give me sleep suddenly, to keep 
away sleep, to develop dreams in me, to wake me up at any time, to lead 
me to any thoughts whatever as also to a definite point by greater tension 
of the electric current (or however this is managed) further to lead 
off the thoughts, indeed even to suggest any movement whatever to me. 
My mind is excited to such an extent and the most incredible thoughts 
come to me chiefly on awaking early in the morning. ... I try to control 
them with the utmost energy ; but with the best will it does not suceeed, 
so long as the machine is active and I must always remember it as, 
besides, my thoughts are directly drawn out. Also in reading, it may 
be anything whatever, I cannot give sufficient attention at all to the 
contents of the book and a side-thought comes to me almost at each 
word. ... I should like to take hold of another point ; that is an 
exaggerated laughing which has often already moved me quite 
peculiarly, though not tormented me, and which I could hardly control at 
all. Thi^ laughing, which is by no means painful, was transmitted to me 
just when I had thought something especially stupid. When one reads 
all this it seems to be the greatest nonsense, that ever was written down ; 
I can, however, make known nothing further than that I have actually 
experienced all this but unfortunately have not understood it. Probably 
only he will understand this who by means of such a machine has been 
already tormented just as I have been ; probably only an expert will be 
able to give further information about it." 

Perception, orientation and the working up of external 
impressions are frequently disordered. The patients often 
mistake persons and surroundings, they are perplexed and 
bewildered, and do not understand their position and what is 
happening around them. They complain that they are no 
longer as they were, that their mind is failing, their thoughts 
are all confused, that they cannot collect their thoughts any 
more ; their memory also is failing. In fact, they sometimes 
make the impression of stupidity and silliness, are confused 
and easily distracted ; ' my mind and sense go lost diiring 



112 DEMENTIA PR.«:COX 

conversation,' said a female patient. Sometimes to the 
simplest questions nonsenical answers quite away from the 
subject are given, while at other times the patients do 
arithmetical calculations quickly and correctly or display a 
fair amount of school knowledge. 

Delusions. — A great number of delusions now invariably 
develop, some of which are most amazing. The anxious 
confusion of the patients is expressed in the idea that every- 
thing is falsified, that false statements are made, that 
there is war in the whole world, that the world is being 
ruined, that they are " in an enchanted house." " It is a 
mystery," said a patient ; the greatest events happen, the 
greatest secret, the greatest wonder of the world, that devils 
come into heaven. The house is on fire, is full of dead 
bodies ; the provincial court was taken by storm, the clergy- 
man was stabbed ; the French are coming ; the physician is 
the examining magistrate, the Kaiser ; every event has a weird 
significance. 

Ideas of Sin. — Very frequently there are also ideas of sin 
especially in the beginning. The patient has misgivings 
about his past life, reproaches himself. He is a wicked 
fellow, has made mistakes, has told lies and committed theft, 
has deceived his wife, has killed his children, has said some- 
thing about the Kaiser, has destroyed religion, has thought 
" Godswine," is to blame for the war, for the death of a noble- 
man, is bringing misfortune on his family ; everyone has died 
on his account. He is the last Judas, is rejected, is damned 
for time and eternity, is the anti-Christ, cannot be saved, is to 
vow allegiance to Satan ; his children are in hell. He is 
looked on as a great criminal, accused of theft, of indecent 
assault ; he must die for the sins of the world. 

Ideas of Persecution. — Not less various are the ideas of 
persecution that are developed. Allusions are made to the 
patients; they are watched, stared at, spied on, laughed at. 
They are influenced by sympathy, bewitched, stunned, chloro- 
formed, hunted like a wild animal in flight. Suspicious 
personages meet them in the street ; there are people in the 
cellar ; the slater will kill them ; the policemen are coming 
to drag them to court. A raven appears at the window, 
which will devour their flesh ; there are serpents in their bed ; 
the black cat is coming ; hellish spirits are threatening. The 
physicians give them poisonous pills, sprinkle poison in their 
ears ; the air is also poisoned ; the breakfast is made dirty 
with urine ; there is human flesh in the food. The patient 
is murdered, executed, burned, cut to pieces, sawn asunder, 
dissected alive, trampled by a horse. His children are ill ; 



CLINICAL FORMS ' 113 

his wife is in prison ; his daughter has been killed ; his 
brother is dead ; his little boy has fallen out at the window ; 
all Jews are being beheaded ; a mother who thought her 
children were in danger, prepared to drown them. At night 
they are ill-treated ; their flesh is tampered with, their breath 
is twisted off, their neck is broken by pressure, their strength 
is drawn out of them, their blood is driven off, the nape of 
their neck is broken, their skull is being proved ; 6ne can 
"tear him with words from below upwards" ; with words his 
"legs can be shaken off." His brain is injured; in his head 
everything is taken part in, thoughts are " made incarnate " ; 
there is another spirit in his body. His nature is excited, his 
semen is driven off, an assault is made ; the nurse makes 
sexual advances. As has been mentioned formerly, the per- 
secutions are frequently connected with the nearest relatives. 
His family will bring the patient to the gallows ; his father 
will kill him ; his mother is a witch ; a female patient asserted 
that she had been sexually ill-used by her father. The wife 
is contaminated by others and will poison the patient. 

The idea of the change which has taken place in the 
patient, often takes very singular forms. The patient feels 
himself weak, gloomy, not right in his head, " not as it ought 
to be." His head is " a rubber tube filled with blood " ; every- 
thing is rebellious in him. His brain will burst, is heavy, 
has broken through ; his understanding is destroyed by 
onanism ; the patient cannot think alone, so cannot live 
outside. He had eaten the disease with a sausage, said a 
patient ; another said that he was ill because of a disappoint- 
ment in England and in Kaiserslautern. His face is a death- 
mask, his heart is dried up, hardened, swollen ; his bones 
rattle ; loops of his intestine come out at his ear ; his blood- 
vessels are burst ; the connection between intestine and 
stomach is broken off; everytliing is torn off and drawn 
together. The patient has no longer a stomach or an 
intestine or a motion ; he has little children in his neck, 
serpents and snails in brain and body, a glazier's diamond, a 
church tower in his breast, a frog in his stomach. He will 
not get better, he will not be alive to-morrow, is not a human 
being any more, is a guinea-pig, the northern lights, is dead, 
no longer in the world, is in another world ; " I am as if 
dead-born," said a female patient. A patient said that he 
must make the Talmud, his wife the Acropolis of Athens and 
then marry a grand gentleman, while he was being murdered. 
Perhaps such senseless utterances are connected with hallucina- 
tions ; Bleuler suggests obscure associations caused by remote 
similarities of ideas or sounds perhaps also indirect associations. 

H 



114 DEMENTIA PRi*:COX 

Exalted Ideas. — In a number of cases exalted ideas are 
present also, mostly for the first time in the more advanced 
periods. The patient will be rich, will have good things to 
eat, get a situation on the railway of the Grand Duke, has an 
excellent memory, possesses means to make people omni- 
scient, has the " imperial attack," must go to the Kaiser. An 
inheritance of a million is being kept back from him ; his 
mother is not his own mother, his father is a Count, Prince of 
Leiningen, the Grand Duke, the Emperor Frederick ; he 
himself is a millionaire. Prince of Hesse, possesses a third 
part of the world ; " Everything belongs to me, but there are 
also shareholders," declared a patient. The patient is divinely 
gifted, is the vicar of Christ, the son of almighty God, feels 
the spirit of the Saviour, is inspired, fights for the faith, has 
the Bible and the world in his head, lives eternally ; the 
spirit goes forth from him ; a patient declared he was the 
bride of the Holy Ghost. Women are "the bride of a 
gentleman in a white suit," hope "to get a husband, 
gentlemanly and aristocratic"; they are countesses, angels, 
" mother of the world," the bride of Christ, their sons are 
princes ; a female patient said she was the Mother of God, 
but had also earned it. 

Mood is at first anxious and depressed. The patients 
mourn, they howl, they break out into convulsions of weeping, 
even though they often seem singularly indifferent in com- 
parison with the delusions to which they give expression. 
Very frequently ideas of suicide come to the surface ; the 
patients beg that something should be put into their coffee, that 
they should be killed because they cannot live any longer; 
that they should be beheaded as they will not get really well 
again. Many patients also make attempts at suicide, some- 
times impulsively with great energy, sometimes more as in 
play. Several patients jumped out at the window ; a patient 
threw himself before a train ; a female patient stabbed her 
breast with a knife A man lay down in front of a beer- 
wagon in order to let himself be run over; another beat his 
head against the wall ; a female patient "tried how drowning 
feels." Not at all infrequently exalted moods are interpolated 
in the periods of anguish, giggling, grinning, and laughing, 
especially in the further course of the malady; al.so states of 
irritated excitement, outbursts of obscene abuse, and sudden 
dangerous assaults on the surroundings often occur. A few 
patients display in the beginning of the disease an ex- 
aggerated piety ; they kneel, they pray, they read pious books 
continuously, they wish to go into a cloi.ster ; a female patient 
procured the robe of a penitent; another reproached the 



CLINICAL KORMS 115 

clergyman in church that he did not preach rightly. Sexual 
excitement is expressed by undressing, taking down their 
hair, improper talk, violent masturbation, which sometimes is 
ascribed to constraint ; a female patient lay down in a 
missionary's bed ; a male patient urinated on his sister-in-law. 

The Activities and Behaviour of the patients have in 
part a certain connection with their hallucinations and 
delusions. They listen at the window, speak secretly against 
the wall, exert themselves to ward off invisible people ; a 
patient begged to be allowed to sleep in the cellar, that he 
might not hear the voices ; another was afraid of the alarum- 
clock. Many preach, wish to confess their sins, ask the 
public prosecutor for protection. A female patient hid 
herself for several days and nights in the forest for fright. 
The aversion to relatives leads not infrequently to hostile 
assaults. A patient threatened his mother with a knife ; 
another was going to kill his father with his scythe. 

Very frequently, however, a motive for the conduct of the 
patients cannot be found at all ; we have rather to do with 
impulsive actions, such as are so frequent in dementia prsecox ; 
for ought we know vague delusions may often play a part. 
The patients throw things on the floor, tear the clothes off 
their body, seize hold of the physician by his face, steal things 
from their neighbours; bite their handkerchiefs ; a patient 
who was given an injection immediately bit the part of the 
skin away. Another set the mill going by night, and then 
set fire to a hay stack, in doing which he was severely hurt. 
Many patients devour bees-wax, dirt, drink the bath water. 
The assaults on the surroundings also may be wholly 
impulsive ; a patient felt himself urged without any compre- 
hensible motive to kill his sister, and stabbed her without 
more ado in the arm. 

But further we meet in the patients here also all the 
peculiar volitional disorders which were discussed before. 
They often show waxy flexibility, often also echo-phenomena ; 
they let themselves be pricked without offering any resist- 
ance ; they assume singular attitudes " on command," make 
faces, blink, utter inarticulate cries, shake their heads, make 
senseless gestures, pull out the hair on their genitals, lie about 
in corners, salivate into their handkerchiefs, behave in a silly 
way, " like a flapper." They speak in a whisper, affectedly, 
mincingly, in a singing tone, using many foreign words, a 
foreign language; they address the physician by his first 
name, carry on confused, drivelling conversations, verbigerate, 
give utterance to silly plays on words and senseless doggerel, 
suddenly break out into bleating laughter. Negativism is 



ii6 DEMENTIA PRyECOX 

also frequent. The patients become unapproachable, give 
either no answer or an evasive one, " because they do not 
need to say it," do not shake hands, " because they have no 
time," hold their hand before their mouth, do not eat because 
they think they must not, or " because they live on the word 
of God," but they take food secretly or appropriate their 
neighbours' food. They force their way out, they resist, they 
do not let themselves be undressed, or they keep no clothes on, 
they lie the wrong way in bed, disown their name, do not trouble 
any more about their surroundings, do not occupy themselves, 
remain lying in bed in a state of indifference. Occasionally 
there is' developed a pronounced stuporous behaviour; ten 
years after the appearance of severe morbid phenomena a 
patient sank for the first time into stupor of long duration. 

The Course of the disease, which generally is progressive, 
was in 14 per cent, of the cases collected here interrupted by 
improvement more or less complete, which lasted as a rule 
one to five years,but occasionally six or seven or even nine years, 
till another exacerbation ushered in a terminal state. This 
issue was in 20 per cent, of the cases a simple weak-minded- 
ness, in which certainly the possibility of dementia progressing 
still further must be reckoned with. Nearly quite as frequent was 
the sinking into states of dementia, sometimes of dull, drivell- 
ing, negativistic stamp, seldomer manneristic. Seizures were 
observed in 27 per cent, of the cases. The form here dis- 
cussed corresponds, therefore, with respect to the final issue 
to about the average, but inclines little to remissions and is 
accompanied with striking frequency by seizures. It 
includes not quite 13 per cent, of all the cases. Of the 
patients 55 per cent were men, this corresponding just 
about to the average ; 48 per cent, had not yet passed their 
twenty-fifth year. This form seems accordingly to prefer 
somewhat the more advanced pv;riods of life, a circumstance 
to which we shall later have to return. 

The Agitated Dementias. 
The next of the larger groups of the cases includes those 
in which states of excitement more severe and lasting longer 
are developed. According to the kind of clinical symptoms 
which appear, but specially according to the clinical course, 
we shall here be able to separate out some subordinate groups. 
Further, I think that on historical grounds I should keep apart 
and later discuss separately that form of dementia praecox in 
which peculiar states of excitement are associated with 
stupor, as it essentially corresponds to the picture of 
catatonia delineated by Kahlbaum. 



CLINICAL FORMS 117. 

Circular Dementia. 

The first subordinate group, which on account of the 
nature of its course we may perhaps name the circular form, 
at first shows a relationship with the clinical form just dis- 
cussed, in as far as it also begins with a period of depression 
and generally is accompanied by vivid delusions. The 
development of the disease takes places gradually in about 
56 per cent, of the cases often after trifling symptoms have 
appeared a long time in advance ; about 18 per cent, of the 
cases begin acutely. The patienis become melancholy, 
anxious, resistive, morbidly contemplative, monosyllabic, 
stare steadfastly in front of them, and express thoughts of 
death. They complain of sleeplessness, nightmares, oppression 
in their head, sleepiness ; they are indifferent, forgetful, have 
an aversion from work, are sometimes restless, irritable and 
violent, suffer from poverty of thought, weak-mindedness, have 
great ideas, but no energ)', as the relatives of a patient stated. 
Not infrequently a distinct morbid feeling exists at the same 
time. The patients are afraid that they are becoming 
insane and ask for help. A patient desired admission to the 
hospital because he had become insane ; such improper 
thoughts were always occurring to him. Another stated that 
he had suffered from his head for a year and his thoughts 
were weakened. A third said that he had been slightly 
weak-minded for three years through onanism. 

Hallucinations are very commonly present, specially 
those of hearing. The patients see shadow-pictures, ghosts, 
dead people, their dead parents, one of their children without 
a head, two devils ; light is reflected on to them and they are 
dazzled. They hear the children screaming, a band of 
robbers with chains rattling in the wall; the bed speaks, the 
devil chats in their ear ; a man who has been hung speaks. 
Their name is called out ; they are hoaxed, mocked, grossly 
abused, tormented with the telephone. Unhappy souls are 
calling ; whole poems are sounded in front of them ; there are 
" secret gosslpings," voices as from a distance, inward voices 
of thought, suggestions, inspirations, the thought-telephone. 
Thoughts are drawn off from the patient, manufactured, 
suggested ; people try to tempt him to suicide ; he must kill 
his child ; God forbids him to work ; he carries on dialogues in 
the distance. " It is the hopper of Niirnberg ; one has it simply 
inside one's head ; the machine is always going on," explained 
a patient. His feet are besprinkled, a stream is carried through 
his head ; a patient had the feeling as if his eyes were being 
pressed out ; a female patient complained of a vulvar smell. 



.ii8 DEMENTIA PRECOX 

Delusions are predominantly of a depressive character. 
The patient feels himself constrained, " inwardly repressed," 
he is " utterly confused " ; " my mind sometimes goes away," 
said a patient ; another said that he was dead ; a female 
patient said that she had lain in chloroform. Their heads are 
hollow, their brains are rent, burnt, their blood and their 
stomachs are in bad condition, their bowels are detached, their 
voice is frozen, their throat is going to close. Something is 
being done to their ears; the patient feels himself influenced 
especially in the night ; there is a transference, "something false 
in things"; "electricity is the whole business." Signs are given ; 
people march with the patient keeping step with him, look at 
him suspiciously, wish to thrash him ; agents, policemen, 
parsons persecute him. He is bewitched, laughed at, teased, 
sold, and sold for immoral purposes, dragged about the whole 
house by night, is an object of scorn and derision ; he is 
sturtned, beaten on his head with a hammer. Filthy and 
unchaste deeds are committed ; a female patient thought 
that she was always having children. 

The husband is dead; the children are" executed ; the 
physician administers poisonous powders ; the patient is to be 
killed, burned, he will have a leg cut off; he knows " what 
happens underground." He is to blame for everything, he is 
the devil himself,- has stolen money, blasphemed God, dis- 
honoured his children and mother, is possessed of the devil, is 
going into the convict prison ; he is being tried by God, will 
suffer, will eat snails for three months and die of hunger ; will 
be forged to chains: his feet are to be cut off; the devil is 
sitting in the wall. His wife wishes to poison him, takes sides 
with parsons ; his father will strike him dead ; his sister-in-law 
is a poisoner ; father and brother take the part of the perse- 
cutors ; he must therefore provide himself with weapons. 
Everything is changed ; the brother is exchanged ; the 
husband is quite different ; a female patient asserted that two 
different men came by turns to her. The physician is the 
Kaiser, the Crown Prince of Sweden ; the companions in the 
bedroom are not patients ; the hospital is the house of the 
kingdom of God, is the girl's school. Everything is on fire ; 
the home is burned down ; famine fever will break out ; there 
is war ; the end of the world is approaching. At the same 
time there are a few exalted ideas. The patient has a higher 
divine calling, is William I., General, Admiral, is successor to 
the Prince of Lippe-Detmold. Prince, son of Count Cotta ; he 
has written three books, is getting an order from the Prince 
Regent of Sweden, has castles ; everything is of gold. He is 
Christ, is being redeemed, has restored dead people to life. 



CLINICAL FORMS 119 

Women are empresses, redeemers of the world, are going to 
marry the physician ; the Kaiser was there disguised ; a 
female patient thought she was a foundling born of a 
man. 

As already appears from the utterances of the patients 
which have been quoted, their consciousness is frequently 
somewhat clouded ; they often have an obscure idea, 
perverted by delusions, of the persons and events in their 
surroundings and of their own position. Many of the 
patients, however, perceived quite well and even were 
always perfectly clear in the most severe states of excite- 
ment. The .train of thought is confused and incoherent ; 
in conversation there appears heightened distractibility, 
interweaving of words just heard, prolixity along with 
persistence in single, ever-recurring ideas. A few of the 
patients wrote sensible letters, while others furnished, also 
in writing, wholly disconnected productions ; a patient sent 
us for a long time innumerable confused postcards. 

Mood is subjected to very severe and sudden change. The 
patients are sometimes "inwardly oppressed," "dejected," 
sometimes immoderately happy ; they implore pardon one 
moment, lament their profligacy, beg that they may be 
saved, and in the next moment they break out in horse- 
laughter. Just as suddenly they fall into the most senseless 
despair, shriek, cling to someone, pray passionately " in 
anguish and distress," cry' and scream like little children ; 
then again they are irritated, grumble, make impertinent 
remarks, threaten, have frightful outbursts of rage, scold 
without measure till they are exhausted. " It always comes 
suddenly in ebullition," said a patient. 

Activities. — The disorders of activity are invariably ex- 
tremely manifold and striking. The actions of the patients 
are only in small part connected with recognizable, though 
morbid motives. They listen for the voices, try to drive 
away invisible forms, pray " for the whole of mankind," 
prophesy, preach, make confession, drink holy water on 
account of their sins, are rude towards their relatives, by 
whom they believe themselves persecuted. A shoemaker 
asked an aristocratic lady in marriage assuming that she was 
interested in him ; a patient with jealous ideas summoned his 
wife before the sheriff-court. 

The volitional expressions of the patients are really 
governed by an innumerable number of the tnost varied 
impulses which arise in irregular sequence from the peculiar 
excitement which is developed here. Many of these impulses 
lead to methodical, although senseless, actions. The patients 



120 DEMENTIA PR/ECOX 

run off aimlessly, even in their shirt, wander about in a circle, 
adorn themselves with gay ribbons, paint the walls, scribble 
over every scrap of paper or stuff, appear bare-footed in the 
public-house, climb on the door, throw themselves over the 
head of the bed " in order to get exercise," suddenly lift the 
physician up in their arms, cut their hair off, undress, make 
aimless journeys, put their hands in the soup, force their way 
with the greatest effort out of the door, wind threads round 
their fingers and ears, play with a torn-off button, wear 
stockings of different colours, go to the water-closet innumer- 
able times. Not at all infrequently they become really 
dangerous to their surroundings. They try to light a fire 
under the bedstead, they throw stones, they spit in people's 
faces, throw patients out of their beds without consideration. 
A patient smashed the sewing-machine to pieces, another 
seized his wife by the throat and threw his children on the 
floor ; a third wanted to cut his children's throats ; a female 
patient tried to kill her youngest child. Many patients ill- 
use themselves, and for days and weeks almost continuously 
they make attempts at suicide before the eyes of the people 
round them, try to throttle themselves, climb up the window 
in order to throw themselves down. Feelings of shame and 
disgust go into the background. The patients strip them- 
selves, hold their hands on their genitals, carry on improper 
conversations, spray dirt)- bath water through their mouth 
and nose, wash themselves with urine, pass urine into their 
slippers, collect their faeces in their pocket-handkerchiefs, 
smear themselves with their excreta and eat them. 

But by far the most characteristic features of the excite- 
ment of our patients are the aimless, impulsive single move- 
ments which sometimes overrun the whole of volition and 
which either give place the one to the other in variegated 
change or are repeated with slight alterations innumerable 
times. The patients rub their hands or clap them, shake 
their heads, turn somersaults, throw the bed-clothes about, 
tumble about on the floor, frisk about, hop, carry out turning, 
scrambling, spreading movements with the arms, twist them- 
selves, tremble, shake themselves, touch or tap objects, bore 
their fingers into their noses, put out their tongues, make 
faces, squint, make singular gestures, squirt, splash and whirl 
in water. Excitement makes itself conspicuous also in the 
movements of expression. They bellow, .screech, scream, 
give commands, preach, recite, shout, cry, sometimes with a 
trumpet voice, sometimes in sweet affected tones ; they sing, 
whistle, pant, snort, clear their throats. As a rule they are 
talkative, mix up different languages, speak with nonsensical 



CLINICAL FORMS 121 

intonation, verbigerate, let themselves go in silly plays on 
words and scraps of doggerel. 

With these are associated singular positions, theatrical 
attitudes. The patients press their body together with their 
hands, lie on their belly or in cruciform attitude on the floor, 
twist their legs round each other. Indications of automatic 
obedience and negativism are also frequently encountered. 
The patients are cataleptic, imitate what is done in front of 
them, scream in concert when others scream ; a patient wrote 
words that were called out to him, in the bath water. Others 
close their eyes, press their lips together, throw away their 
food, crumble the bread that is offered to them, and then 
eat secretly or snatch food from others; they sleep standing,* 
go naked to bed or lie the wrong way, do not shake hands, 
lie down in other people's beds, hide themselves away, retain 
their urine. The patients are often to some extent aware of 
the volitional disorders which come to light in their actions. 
" I can't work as I should like," said a patient. " The will is 
there, but I can't get it out," said another ; a third declared 
" Others work outside with my mind." The patients' explana- 
tion of the nonsensical actions is that they were under com- 
pulsion, that there was constraint in them. 

The severity of the states of excitement here described is 
subject to great fluctuations. It can rise from the slightest 
restlessness even to unheard-of violence endangering life. 
There are patients who for weeks and sometimes even for 
months are almost continuously in a state of the most sense- 
less excitement. Meantime as suddenly as the excitement 
appeared, just as abruptly it may again disappear ; it is 
exactly the alternation between complete quiet and stormy 
excitement, which often occurs in the most surprising way and 
isfrequently repeated, which is specially peculiar to the disease. 
The duration of these states is also very variable. Sometimes 
there are only short interpolations -lasting a few days or 
weeks ; in other cases a constant restlessness continues for 
months and even for years, which frequently rises to more 
severe states of excitement even in fairly quiet interludes. 

The course of the disease, which in general progresses 
from depression through excitement to a terminal state, was 
interrupted in 53 per cent, of the cases by periods of con- 
siderable improvement, in nearly 14 per cent, even several 
times. These remissions lasted in the half of the patients 
concerned up to three years, in the other half up to ten 
years. In 70 per cent, of the cases the improvement was 
interpolated after the preliminary depression ; several times 
periods of depression preceded, separated by more lucid 



122 DEMENTIA PR.ECOX 

intervals. After the improvement the disease then generally 
continued with a state of excitement leading to dementia ; 
less frequently a state of depression was again interpolated 
and the first excitement followed. In those cases which 
only improved after a preliminary depression with excite- 
ment following, the relapse usually began again with a state 
of excitement leading now to dementia ; less frequently a 
state of depression was once more interpolated, or psychic 
weakness was developed gradually after the expiration of 
the more lucid interval without more striking morbid pheno- 
mena. The duration of the attacks till the terminal state 
was reached, was sometimes only a few weeks or months, more 
rarely one to two years. The issue was in almost a quarter 
of the cases simple weak-mindedness ; the same number of 
patients sank into complete dulness, while in the remaining 
cases sometimes more a talkative incoherence, sometimes 
more an odd manneristic behaviour, here and there also 
negativism, accompanied the psychic decline. A patient 
died in the course of a very severe and lasting state of 
excitement without organic disease. Seizures occurred in 
one-fifth of the patients. According to the course and issue 
the form here described may therefore be termed a com- 
paratively favourable form of dementia praicox. It includes 
something over 9 per cent, of the cases made use of in this 
enquiry. The share of the male sex with 53 per cent, corre- 
sponded nearly to the average ; as 61 per cent, of our patients 
had not yet passed their twenty-fifth year, it seems in com- 
parison to the general average number of 57 per cent, that 
in these forms which run a more favourable course, the 
younger patients are somewhat more largely represented. 

Agitated Dementia. 

As second subordinate group, an agitated form, we bring 
together those cases in which the disease begins with a 
state of excitement and then directly or after more or less 
numerous remissions and relapses, passes into the terminal 
state. The development of the di.sease is accomplished in 
45 per cent, of the cases suddenly, while in about a third of 
the cases for a considerable time prodromal morbid pheno- 
mena have been noticeable. As a rule the patients become 
e.xcited, irritable, insubordinate, violent ; they run away, carry 
on nonsensical, disconnected conversations ; sometimes a 
conditifin of great confusion appears quite abruptly. 

Hallucinations, especially of hearing, play a considerable 
part here also. The patients see fiery balls, must " watch the 



CLINICAL FORMS 123 

light day and night," must watch the "dazzh'ng h'ghts," 
Pictures are put before them ; they see four people swinging 
who have been hung ; they see mice, ants, the hound of hell, 
a white star, devils, angels, black men, people with knives, 
scythes and axes. They hear cocks crowing, shooting, birds 
chirping, spirits knocking, bees humming,, murmurings, 
screaming, scolding, voices from the cellar, or from above 
downwards ; the walls speak, ghosts talk, there is chatting 
going on in their body. The voices say " filthy things," "all 
conceivable confused stuff, just fancy pictures " ; they speak 
about what the. patient does, "as if he had arranged some- 
thing," they reproach him for eating too much, they comfort 
him. They say : " That man must be beheaded, hanged," 
*' Swine, wicked wretch, you will be done for"; his wife calls 
out, " Beast of a fellow ! " the death of the patient is discussed. 
Visual and auditory hallucinations are often connected. A 
patient saw an angel who announced to him, " Make atone- 
ment, I will crown thee " ; it was said to a female patient by 
a child whom she saw lying beside her: " Wait, till I get 
you ! " The voices proceed sometimes from God, sometimes 
from the devil, from spirits and ghosts, from the mayor's 
daughter ; there are people under the bath. Machines repieat 
what the patient thinks, his thoughts are open to others ; they 
are drawn off, and strange unfavourable thoughts, such as 
come from the devil, are suggested. The angel Gabriel com- 
mands ; " voice-interference " takes place. The patient is 
stupefied by smelling-stuff ; the air, the food is stinking, they 
contain dirty things ; the water is salt. People spit in his 
face, treat him with electric currents ; he feels the shocks, is 
strangled, is rocked ; at night a lieutenant pulls him by the 
genitals ; he is cupped every evening ; he can get no air ; in 
his bed there are fleas and vermin ; " they make a man tired." 
A patient had a feeling as if everything were breaking down, 
and called out : " I am falling." 

Perception and Understanding of the Surroundings 
are frequently disordered. Many patients are as if lost in a 
dream, are perplexed, say that everything is muddled, every- 
thing turned upside down ; the world is being ruined ; there 
is a religious war ; the axis of the world is tilted over. They 
mistake people, call the physician their father, the local 
member of the School Board the Duke of Orleans, the 
Saviour ; they call a fellow-patient their sister ; they are in 
a manufactory, in France, in a nunnery, in church, in the 
*' Schnallenhallenhaus." At the same time they are as a rule 
poor in ideas, distractible, monotonous in their utterances, 
they weave in words which they have heard without under- 



124 DEMENTIA PRECOX 

standing. Through this the condition acquires the features 
of acute confusion, especially when vivid hallucinations are 
present, and is frequently so interpreted. Other patients, 
however, always remain surprisingly clear, make suitable 
remarks, solve problems in arithmetic quickly and correctly. 

Delusions, are connected at first with the feeling of the 
change experienced. The patients feel themselves "confused 
and constrained," " not right in the head," " scattered in their 
mind," quite bewildered, " so confined " ; they have *' such 
childish things in them," they do not know what they should 
say. Everything is destroyed in their head, "evaporated," 
" completely done for." " I was a stupid fellow from the 
beginning," declared a patient; another said," I am no longer 
as I was, had no more thoughts, did not know where I was 
going;" a third said, "I am quite stupid, I know nothing 
more "; a fourth, " I am becoming half mad, I can no longer 
understand anything." Other hypochondriacal ideas are also 
expressed. The patient has fever, phthisis, pains in his 
body ; he cannot breathe, has just almost died ; his blood is 
not moving ; his arms are cut off, are sometimes fatter, some- 
times thinner; his limbs are changed, his body burned, his 
leg^ are broken ; a little monster is sitting on his chin, a 
bludgeon on his back ; there is wax in his body, cold in his 
brain ; a patient thought that the one half of him was male, 
the other female. 

Ideas of Sin, of Persecution, and of Influence. — Ideas of 
sin play a small part. The patient has done everything bad, 
is a Jacobin, anarchist, and nihilist, is going into the convict 
prison ; the evil one is fetching him. Neither are ideas of 
persecution much in evidence. The patient leads the life of 
a martyr, gets hard, mouldy bread and the smallest pieces of 
meat, does not get the right wages, is being poisoned with 
prussic acid, is being persecuted by the magistrates, by a 
servant girl, is regarded as a spy, is chosen by his family as 
the sacrificial lamb ; at night his bed and clothes are .soiled ; 
people are going to take his money from him. He is to be 
murdered, thrown into a grave, does not want to go to the 
scaffold. A misfortune is going to happen ; a flash of lightning 
is coming ; his parents are burned ; his sister has died ; his 
wife has hanged herself Not infrequently we meet ideas of 
influence. The patient feels himself magnetized, under a ban, 
as if electrified, influenced by God, by the look of the attendant ; 
he has a machine in his body ; everything that he does is 
destiny ; he mu.st stay in bed "on command." His cough is 
made by the physicians ; people attack him at night, torment 
him, will make him mad ; " the beastly swine were at me," 



CLINICAL FORMS 125 

said a patient. Female patients are raped, chloroformed, and 
dishonoured ; a female patient believed that she had become 
pregnant by a shadow and that abortion had been committed. 
Exalted ideas are the most frequent. The patient feels 
himself destined to great things, works beside royalty, can 
put anyone into prison, speaks many languages, is to be a 
professor, will teach at a university, is getting an inheritance 
from the Australian Kaiser, possesses fifty estates, millions. 
He is Li-Hung-Chang, Prince, son of the King of Wiirtem- 
berg. Majesty, Napoleon, Kaiser ; a patient asked on admission 
if the European Concert had been informed. The patient 
receives revelations from God, is going to write a book about 
a new Christianity, is going to redeem the world, has wrestled 
with the devil, was in heaven ; he is the " father of his own 
mother," mediator between God and men," Lord Holy Ghost," 
is waiting for redemption, for the last judgment. He can 
heal the sick ; he will do away with menstruation in women ; 
no one is going to die any more. Female patients become 
rich women, have money in the savings-bank for their 
children, are getting a Lord Mayor for a husband, are to 
marry a priest. A female patient declared she was the Queen 
of Heaven, and wished to have a private water-closet. The 
following extract from a letter may give an idea of the sense- 
lessness and incoherence of the delusions : 

" Let it be your business, dear T., that you in the new year have the 
empty room put full of continents and increase your fortune and your 
fame to the infinite. In this case you will take the second place in the 
world and will have a happy future. Millions of continents are given to 
your care and providence and happy in your theism. That you till now 
are still lethargic, that can finally be redressed and we shall hope the 
best for you. Lethargy is devil's work and needs presumably time for 
removal. But how to remove your argie? It's that that causes me 
trouble. Drink plenty of wine and beer and move about a great deal 
in society, then it will pass. You will not finally get rid of your creation- 
stain at all — A merry life and fortunate future. 

With hearty partial honour-sympathy your friend and brother 

H.H. (Name of the superintendent of the institution). 

" Holy Ghost and third person in the Godhead. 

" Nota bene : obediently to serve that I must later generate a son 
from myself; he will receive the title 'Son of God,' and will be generated 
as from the holy third spirit and received as second person in the God- 
head. Otherwise we have with us no splendour and no consideration. 
Upon you, dear T., I bestow as New Year's present the title 'glorious, 
sole councillor and dear almanac.'" 

Mood is in general exalted, more rarely anxious, but 
always subject to extraordinarily sudden and severe fluctua- 
tion. Whimpering, bewilderment, wild laughing, frightful 
outbursts of abuse, unrestrained merriment may make place 



126 DEMENTIA PRECOX ' 

for each other without intermission. The behaviour of the 
patients towards their relatives shows complete indifference. 
Sexual excitement is expressed in masturbation, indecent 
assaults, jealous ideas, and exposure of themselves ; a female 
patient hung her bloody chemise in front of the window. A 
patient was very much irritated by his father who, he said, 
always forced him to masturbate ; another felt himself 
constrained to cohabit with his sister. Now and then homo- 
sexual tendencies come to the front. 

States of excitement have the same features as in the 
group last described. Only within narrow bounds does the 
behaviour of the patients appear to some extent compre- 
hensible. Thus there might be a connection with religious 
delusions when a patient rings the bells by night, lights the 
altar candles, begins to preach in church, takes objects from 
the altar, wishes to open graves, burns the stigmata on 
himself with his cigar. Ideas of persecution lead to the 
patients wishing to appeal to the police, to provide them- 
selves with a revolver, to make a visit " only with a strong 
escort," to cut their wife's throat. Patients with exalted 
ideas make purchases, make senseless presents, forge plans 
for getting engaged, write letters to Grand Duke and Kaiser, 
wish to go to Rome to liberate the Pope. Those with ideas 
of sin kneel, pray, beg for forgiveness ; a female patient put 
on her Sunday clothes and was going to jump out at the 
window in order to reach God, because she had not confessed 
everything. Hallucinations have as a consequence that the 
patients stop up their ears with paper and bread, and try to 
chase away spirits (" away with the devil ! ") ; a female patient 
threw the goldfish into the water-closet because they carried 
on blasphemous conversation. 

But on the whole the excitement consists of impulsive 
actions and senseless movements. The patients run aimlessly 
about, play tricks, mix up their bedclothes altogether, tear 
up and destroy things, throw chairs and spittoons about, 
smash panes of glass, fling their food about the room, throw 
their watch down the water-closet ; they march out naked, 
they throw things at the burning lamp. Others scratch their 
faces, dash headlong out of bed, stick the handle of a spoon 
into their anus, pull out their teeth, try to strangle themselves, 
beat their faces, pull at their genitals, at their ears, all being 
done impulsively, suddenly, with great violence and without 
recognizable motive. The very frequent and dangerous attacks 
on their surroundings also bear the same stamp. The patients 
without any consideration throw their relatives on the floor, 
knock down a neighbour, rush at an unknown person with a 



CLfklCAL FORMS 127 

fork, bite the arm of the attendant ; a patient took hold of an 
attendant's finger so firmly with his teeth that he could only 
be made to let go under an anaesthetic. The senselessness of 
these actions is made clear by the fact that the patients one 
moment impetuously embrace a person and next moment 
perhaps belabour him with their fists. 

But besides these actions, which after all have a Certain 
relation to the surroundings, a disorderly series of completely 
aimless movements are further carried out, usually with a 
tendency to innumerable, uniform repetitions and to rhyth- 
mical arrangement. The patients run round at a gallop 
always the same way, run round the house till they are 
exhausted, they jump up and down with great leaps, march 
in the garden " as if they had the strictest order from the 
colonel," cut capers, dance about singing, carry out military 
movements, "physical drill," flourish their arms, beat time^ 
knock and drum on the bedstead, turn round about, write 
figures in the air. They let themselves fall on the floor,, 
waltz round about bellowing, prance, fall over and roll about, 
grind their teeth, pull hideous faces, spray and spit about 
them. In its most simple forms this restless movement 
becomes stretching, shaking, trembling, choreic jerking of the 
hands, tripping and stamping, balancing and rocking, dis- 
torting of the arms and legs, as we find it again in the 
terminal states as a residuum of the severe and acute volitional 
excitement. In the domain of the movements of expression 
the excitement makes itself conspicuous in singing and play- 
ing the harmonica for hours, in shrill screaming and screeching^ 
in the inarticulate utterance of senseless sounds, in cease- 
less flow of words, reciting, rhyming, scolding, panting, 
groaning, hissing, whistling, sighing ; some patients say 
everything singing ; others speak in gibberish invented by 
themselves. 

Besides the impulsive discharges th^ signs of the other 
volitional disorders which are peculiar to dementia praicox 
are also invariably found here. The movements, actions and 
attitudes of the patients are frequently manneristic, some- 
times clumsy and awkward, sometimes affected and florid. 
The patients assume odd attitudes, twist themselves together, 
balance themselves, hold the lobe of one of their ears tight 
for months, behave in a theatrical manner, only give the 
finger-tips in shaking hands, bolt their food without chewing 
it, dress their hair in an extraordinary way. A female 
patient sewed white figures on to her jacket ; a patient knelt 
down each time he came in or went out. Others speak in 
a stilted manner, with high-sounding phrases ; a patient 



128 DEMENTIA PRECOX 

wrote letters in dog-Latin. Frequently automatic obedience 
is present, the patients imitate and follow closely. Negativ- 
istic phenomena also meet us almost everywhere. The very 
inaccessibility of the patients and their want of susceptibility 
to influence might be interpreted in this sense. They do not 
listen to what is said to them, obey no injunctions, do not let 
themselves be disturbed in any way in their senseless on- 
goings, not even by force, do not show the slightest 
consideration for their surroundings. They give no answers 
to questions or else nonsensical or unrelated ones ; they 
arbitrarily apply names to people whom they recognize 
correctly. They crouch under the bed-cover, stick their 
head under the pillow, endure no clothes, do not remain in 
bed, do not change their shirt, do not let themselves be 
undressed, retain their urine and then soil the bed, eat only 
when unobserved or eal the food of other people, keep their 
bread for hours in their mouth. A patient let himself be 
only half shaved, then ran away ; a female patient tied on 
her apron the wrong way. , 

Here also the severity of the excitement may be of very 
varying degree, from slight silly restlessness to raving mania 
of the most- severe type. The impulse to movement may 
become so uncontrollable and so regardless that it seems 
scarcely possible to procure any rest even for a short time 
for the patients and their surroundings. Bruises and abrasions 
and even more serious injuries can in certain circumstances 
not be prevented at all. At the same time the sense of many 
of the patients is very surprising ; they may be quite clear 
about their situation and surroundings, but just as surprising 
is then the abrupt commencement and the equally sudden 
cessation of the excitement which often appears in the 
form of limited attacks of shorter or longer duration. 

Course. — The states here described may pass after many 
fluctuations directly into incurable states of weakness. In 
36 per cent, of the ca.ses, however, after the first attack there 
is a remission of all morbid phenomena, which in 10 per 
cent, of the cases may even be repeated once or indeed 
several times before the terminal state is reached. The 
duration of these periods of improvement fluctuates from a 
few months to twelve or fourteen years ; it is most frequently 
about three years. The recurrence of the disease occurs 
usually with fresh states of excitement, somewhat seldomer 
in the form of progressive dementia, now and then also 
perhaps with a state of depression to which excitement may 
again follow, terminating in dementia. When there are 
repeated remissions of the disease the states of excitement 



CLINICAL FORMS 129 

may return more frequently. In one case I observed first 
four states of excitement separated by periods of improve- 
ment lasting for some years, of which two terminated in 
depression ; then there followed after a clear interval of fifteen 
years a state of confusion which led to a final state of 
dementia, which I followed for eight years. 

A simple weak-mindedness of varying degree was the 
issue in 27 per cent, of the cases of the form here described. 
Nearly in the same ratio a state of dementia with marked 
mannerisms was the result, somewhat seldomer a psychic 
decline with predominating incoherence or with dull indiffer- 
ence; one patient died by suicide. Seizures were observed in 
approximately a fifth of the cases. Evidently we may regard 
this form also of dementia pra^cox as relatively favourable. 
It includes about 14 per cent, of the total number of our cases. 
The male sex was represented by 60 per cent., and the ages 
under the twenty-fifth year were the same ; in both directions, 
therefore, the numbers are somewhat over the average. It is 
perhaps not without interest to remark that the form described 
seemed to me to be by far the most frequent among the 
numerous cases of dementia praecox observed among the 
natives of Java. 

Periodic Dementia. 

In close connection with the cases brought together in 
the last section we have still to mention a small group which 
runs a pronounced periodic course either in the introductory 
stages of the disease or during its whole duration ; its number 
amounts to not quite 2 per cent, of all cases. The outbreak 
of the disease occurred in two-thirds of my cases before the 
twentieth year, sometimes at fourteen years of age. With 
shorter or longer intervals, often very few weeks, sometimes 
only once a year, confused states of excitement appear which 
run a rapid course. In the female sex they are frequently 
connected with the menstrual periods in this way, that the 
attack begins with the commencement of the menses or even 
a short time before, and then lasts about one or two weeks 
till it makes way for a clear interval lasting usually somewhat 
longer (" menstrual insanity "). The commencement of the 
excitement is as a rule quite sudden. After at most slight 
indications of the commencing attack, causeless laughter, 
blinking of the eyes, wandering about, have preceded, there 
is developed from one day to another, often in the middle of 
the night, the picture of maniacal excitement. Sometimes it 
is limited to heightened irritability, change of mood, restless- 

I 



130 



DEMENTIA PRECOX 



ness, incessant chatter ; but gradually the excitement becomes 
worse, going on even to raving mania of the most severe type, 
often with delusions and hallucinations. The body weight 
invariably decreases rapidly, sometimes as much as five to 
eight pounds in twenty-four hours (Furstner). Fig. 25 shows 
the fluctuations during a prolonged series of attacks up to 
death. The excitement often lasts only a few days or weeks, 
more rarely it continues for months and then is interrupted 
by only a few quiet days. Usually the intervals are some- 
what longer, a few weeks or months. In course of time the 
duration of the attacks may be extended. 

The commencement of the quiet period takes place usually 
just as quickly as that of excitement, even though one can 
generally notice already towards the end of the attack a 
slight decrease of confusion and restlessness. The patient 





A _, f^ h ^^hjs /Tj . * 


A±57rn3tTEr47^T . 


I^^JV jr^JTlL^v^^'^UTlv 


4 ^^^ ^ hXv 


1 it ^r 


X 


I 


i 



Fig. 25. Fluctuations of body weight in periodic excitement. 

is now all of a sudden reasonable, but remarkably quiet, 
indifferent, dull, and has not as a rule complete insight into 
the morbid nature of his state even though he still remembers 
well many details. He rather tries to represent the excite- 
ment, which he has gone through, as something quite harm- 
less or as caused by the surroundings, the restraint in the 
institution and that sort of thing. He considers himself 
already on the first day of the commencing state of quiet 
as completely recovered, and urgently desires to be dis- 
charged. A certain physical improvement usually takes 
place rapidly, but during the interval which now follows the 
body weight frequently remains lower than it was before 
the onset of disease. 

After a considerable number of attacks there frequently 
occurs a considerable, or even lasting, cessation. Or the 



CLINICAL FORMS 131 

attacks are prolonged and are only interrupted by short, 
comparatively clear intervals. In a small number of cases 
there may finally be developed a quite regular alternation 
lasting for decades between short periods of the most severe 
excitement and of quietness. In a patient whom I observed 
there had developed a daily alternation, setting in with the 
greatest punctuality between behaviour in every way suitable 
for society and the most violent raving mania, which lasted 
at least for ten years. But it invariably comes to the 
development of marked psychic decline, which sometimes 
has more the features of a simple weak-mindedness with 
poverty of thought, lack of judgment, emotional dulness and 
weakness of volition, sometimes is accompanied by incoher- 
ence and affectation. In contrast to the excess of men in 
the other forms, two-thirds of these patients were women, 
in whom obviously the periodicity of sexual life favours the 
development of the form which runs this course. 

Formerly I regarded these forms as belonging to manic- 
depressive insanity. Without doubt in this disease also there 
are attacks of similarly short duration. Meanwhile the states 
of excitement here described which are repeated in short 
periods of time often form only an episode in the course 
of a disease which otherwise undoubtedly is dementia 
praecox ; further, the states of weakness which are developed, 
bear the features throughout of the decline geiTerated by that 
malady. These experiences have made me change my 
opinion. There is also the fact that the states of excitement 
themselves, with their monotony, impulsive character, and 
poverty of thought, resemble much more those of dementia 
praecox than those of mania. Again the circumstance might 
be pointed out, that periodic states of excitement are also 
otherwise very frequent in dementia praecox. Lastly, one 
might bring forward the fact that occasionally inherited 
relationships can be proved between this and other forms 
of dementia praecox. Accordingly one may represent it to 
oneself somewhat in this way, that a peculiarity of the malady, 
which usually only develops later, dominates the clinical 
picture in the cases here discussed specially early and in 
specially high degree. 



Catatonia. 

The states of excitement of dementia praecox form 
also an important constituent part of that clinical form 
to the consideration of which we have now to turn, cata- 



132 DEMENTIA PRECOX 

tonia.^ Under this name Kahlbaum has described a clinical 
history which presents in series the symptoms of melancholy, 
of mania, of stupor, also in an unfavourable course those of 
confusion and dementia, and besides is characterized by the 
appearance of certain motor spasmodic and inhibitory pheno- 
mena, just the "catatonic" disorders. The description given 
by him, in many respects masterly, should demonstrate that 
all conditions till now named melancholia attonita, stupor, 
acute dementia, and so on, are in reality only manifestations 
of a single psychosis, which, like dementia paralytica, in 
spite of external differences in the course, still exhibits a 
number of wholly peculiar bodily and psychic morbid 
symptoms. 

As far as we can take a general view of it to-day, the 
statement of Kahlbaum must be regarded in a certain 
direction as too narrow but in another as too wide. Later 
experience has taught that the catatonic morbid conditions 
can nowhere be sharply separated from the remaining forms 
of dementia pra:?cox. Much rather not only are certain 
fundamental features of the clinical picture common to both, 
but single catatonic morbid symptoms frequently meet us 
also in forms of the disease otherwise wholly divergent. 
As further in all remaining respects, in the conditions of 
development, in the course and specially in the issues, and 
lastly, so far a^ a judgment on the subject is possible to-day, 
also in the post-mortem findings, no decided differences are 
recognizable, we may regard the catatonia of Kahlbaum as 
in the main a form, though peculiar, of dementia praecox. 
On the other hand " catatonic " morbid phenomena are 
undoubtedly also observed in many quite different morbid 
processes to a greater or less extent, so that its appearance 
alone does not justify the conclusion that catatonia in the 
sense just indicated is present. In this direction accordingly 
we must limit the conception mentioned, that only such cases 
of disease belong to it, in which the morbid process of 
dementia praecox is the foundation. How far and by what 
symptoms we are able already to recognize that to-day, must 
be discussed later. 

The course of catatonia in the single periods above 

' Kahlbaum, Die Kalalonie oder das Spannungsirresein. 1874 ; Brosius, 
AUgem. Zeitschr. f. Psychiatric, xxxiii. 770 ; Neisser, Uber die Katatonie. 1887 ; 
Behr, Die F'rage der Katatonie oder des Irreseins mit Spannung. Diss. Dorpat. 
1891 ; Schiile, Allgeni. Zeitschr. f. Psychiatrie, liv. 515, Iviii. 221 ; Aschaffen- 
burg, ebenda, 1004 ; Meyer, Archiv. f. Psychiatrie xxxii. 780 ; Tschisch, 
Monatsschrift f. Psychiatrie vi. 38. 1899 ; Arndt, Centralblatt f. Psych, xxv. 81. 
1902 ; Claus, Catatonic et stupeur. 1903 ; Pfister, Allgem. Zeitschr. f. Psychi- 
atrie. 1906, 275. 



CLINICAL FORMS 133 

mentioned is, as Kahlbaum himself has already said, not 
inviolable, but it represents only in a certain degree the 
general framework, in which the divergent cases approxi- 
mately find a place. The really characteristic pictures of 
the state are rather the " mania " of Kahlbaum, which to-day 
we more correctly name catatonic excitement and stupor, I 
think, therefore, that I may group together as catatonic forms 
of dementia prctcox those cases in which the conjunction of 
peculiar excitement with catatonic stupor dominates the clinical 
picture. It is true that states of stupor are occasionally 
interpolated for quite a short time or by slight indications 
also in the states of excitement hitherto described. In this 
way gradual transitions arise to the catatonic forms now 
about to be discussed, in which both conditions, apparently 
so opposed to each other, come under observation along with 
or after each other. 

The development of the disease takes place in 41 per cent, 
of the cases acutely, in 31 per cent, insidiously, otherwise 
subacutely. In 47 per cent, of the cases a state of depression 
forms the introduction ; an acute commencement is in these 
cases somewhat seldomer. The patients become reserved, shy, 
introverted, absent-minded, distracted, indifferent, irritable, 
taciturn ; they stand about, carry on unintelligible conversa- 
tions, pray, go often to church, get up at night, eat and sleep 
badly. At the same time they give utterance to a great 
many delusions frequently quite extraordinary ; there come 
" temptations," " presentiments." They have evil thoughts, 
feel themselves lost and abandoned, proscribed. They feel 
uneasy, as if someone were persecuting them ; their life is 
no longer of any value ; everything has turned out badly ; 
no one can help them. They are mocked by bad women, 
maligned, spat on, grossly abused ; they are to be taken to 
the convict-prison, condemned to death, slaughtered, buckled 
on to the railway ; their house is to be blown up ; their 
family is trying to take their life, wants to be rid of them. 
The chopping-knives are already being sharpened ; people 
are coming to fetch them ; their daughter is being murdered; 
their children are going to the scaffold. Everything is being 
taken away ; the stove-pipe is stopped up ; murder and 
robbery are being committed on their mother. Their food 
is poisoned, lard is in the coffee ; in the soup there are 
worms and human flesh ; poison is being blown on them ; 
the flies must bite the patient ; his hair is being torn 
out. 

Ideas of sin are frequently associated with these 
delusions. The patient is more wicked than Judas is the 



134 DEMENTIA PRECOX 

" old eternal swine," a traitor, not worthy to look in the 
mirror ; he has led a dissolute life, has not prayed enough, 
has nailed the Saviour to the Cross, murdered his children, 
is bringing everyone to misfortune. He has three evil spirits 
in his head ; he must always remain in life because the devil 
is hiding in him ; he wishes to do penance. People reproach 
him that he has stolen, that he has assaulted a child ; he is to 
renounce his faith, is in alliance with the evil one ; he is 
to get a prayer-book and holy water, is to have his head 
chopped off. Many patients defend themselves against the 
supposed reproaches ; they have done nothing, do not want 
to be killed. The ideas of sin are expressed very clearly in 
the following document written by a patient : 

" I am a whole world of mean actions and of secret and open vice, I 
believe, therefore, that I only do damage with my filth of mean actions 
and evil deeds, in short in all domains just where I am. I am too 
cowardly to die a hard death or a lingering death and think therefore it 
is now about time to die entirely by means of a revolver. A noxious 
person in every way, I am really not worth powder and shot, and have 
never been an iota of use to you, on the contrary only done you a 
thousandfold damage, just for this reason away with me, completely 
exterminated." 

Often a state is developed of perplexity and confusion. 
Everything is enchanted, changed, full of entanglements and 
complications, bewitched ; the patient believes that he is in 
an enchanted castle, in China, in heaven ; he fights battles 
with death and devil. There is war ; the heavens are falling ; 
there is a fire ; the house is falling in ; the end of the world 
is imminent, the Palatinate is being consumed by fire. The 
patient is being made ill by treacherous people, does not 
know himself any more, feels himself "quite darkened," 
appears strange to himself; the furniture does not belong to 
him ; the visitors are not the right people. He takes his 
fellow-patients for his relatives, for princes, the physician for 
the black devil, for Jesus, for the King. All human beings 
have been destroyed ; there is no one any longer at home ; 
everything is being taken away, the safe is being broken 
into. 

Hypochondriacal ideas. — These occur very frequently. 
The patient has pain in his limbs, pressure in his throat, 
poison in his body, phthisis, dropsy, he must die. His semen 
has gone inwards ; his bones are growing out of his body. 
His feet are black, his hands have rotted ; a patient thought 
that he was dirty and washed himself continuously. His 
stomach runs up and down ; blood forces its way out at 
mouth and nose ; fire issues from his mouth ; his faeces are 



CLINICAL FORMS 135 

alive. His throat and anus have closed up ; his h'mbs 
become smaller ; his eyes have been gouged out ; the patient 
has a club-foot, chloride of lime in his bones, is full of grass 
and moss, is shut up with a pane of glass. He suffers from 
headache, his head is empty, he has diphtheria in his brain, 
beetles in his head, cannot speak ; his memory has suffered 
much. 

The Feeling of Influence also often plays a part in the 
delusions. The patients feel themselves " influenced by 
magic power," "governed by invisible power." At night 
" electro-magnetic practices are carried on " ; their nature is 
caused to pass from them ; they are made crazy ; they must 
think filthy thoughts, do what the mediums wish ; they are 
hypnotized by the physician. 

Exaltation. — Here and there ideas of exaltation appear 
beside those of depression. The patient is Gustavus 
Adolphus, King of Hungary, a great athlete, will go to 
Vienna and there become Kaiser, inherits money from his 
fiancee, gets 60,000 marks from God, wishes to marry, to go 
to America by the lightning-express, to redeem mankind, 
to make other laws ; he is the emperor-angel, has revelations 
in the spirit, wants milk from angels. Female patients are 
" Queen on the Rhine," " Heaven's child," become engaged 
to the Kaiser, wish to marry Jesus, an officer, have a secret 
love affair, are pregnant, possess castles, ten millions. A 
servant girl asserted that the son of her employers had 
offered 70,000 marks for her ; another related that she was 
getting three crowns before her execution. Usually these 
delusions are fairly fleeting and indefinite, and are given 
expression to without special emphasis. A patient said 
he did not know whether his mother was Queen of England, 
or Kaiserin, or a cook. 

Hallucinations are invariably present, especially those of 
sight and hearing. The patients see apparitions of light, 
figures, three faces at the altar, devils, dogs, snakes, soldiers, 
policemen. They hear music, voices of birds, cries for help, 
voices from the stove and water pipes, from their own body, 
" from the hind." There is singing in the wall ; the apparatus 
is crazy under the bed ; the clocks are speaking ; outside 
they are blustering ; the Christ-child speaks ; their mother is 
weeping ; husband and daughter are calling out ; dogs are 
barking. Gentlemen are telling wicked stories ; the devil 
calls out the name of the patient ; God announces to him that 
he must die, carries on conversations with him ; the Kaiser 
challenges him to a duel with pistols ; people mock him, call 



136 DEMENTIA PRECOX 

him abusive names ; " Goose," " Good-for-nothing," " wicked 
fellow," threaten to tear out his throat ; a voice in his head 
reproaches him. A female patient perceived that she had a 
secret love affair, and said, " I have that so in hearing." 
Many patients have their thoughts said to them ; others 
receive commands, "Hands up"; a female patient heard 
" all the letters of the alphabet," and had to count. Here 
and there the voices have a rhythmical cadence. Some 
patients feel themselves breathed on, blown on, tormented 
with rays, electrified, feel needles in their hands, smell the 
smell of corpses ; one patient stated that he had "experienced 
much in his genitals." 

States of Excitement. — After the introductory depres- 
sion theVe usually next follows a state of stupor, especially in 
men, and then excitement ; more rarely is it the other way. 
On the other hand the cases setting in without depression 
begin according to my experience somewhat more frequently 
in the form of a state of excitement, the picture of which 
essentially corresponds to that of the agitated form previously 
described. The patients become restless, sleepless, run about, 
carry on absurd conversations ; their actions are impulsive 
and aimless, and they fall more or less rapidly into severe 
excitement ; sometimes raving mania may break out quite 
suddenly, even in the middle of the night, perhaps after 
insignificant prodromal symptoms which have not been 
noticed at all. Mood is usually exalted. The patients laugh, 
try to be witty, make jokes, tease other patients, boast, carry 
on unrestrained conversations ; here and there religious 
ecstasy is observed. But very frequently the patients are 
also irritated, angry, threatening ; they break out into wild 
abuse, fly into a passion on the slightest occasion, make 
dangerous attacks without consideration. More rarely they 
are anxious, whine, cry, groan, wring their hands, beg for 
their life, scream " murder ! " " Satan, begone ! " ; they do not 
wish to go to the war ; they prepare for death. But invari- 
ably the colouring of the mood is subjected to swift and 
astonishing change. Angry irritation is abruptly interrupted 
by a jocular remark ; the patient who has just been lament- 
ably afraid of Satan, suddenly calls out laughing, "The 
wicked one has gone ! " Many patients laugh and weep 
confusedly, and sing merry couplets amid tears. Very 
frequently there is extreme sexual excitement, which is made 
known by jealous ideas, shameless utterances, movements of 
coitus, regardless exposure and masturbation. A female 
patient tore her chemises down the front; others grasp at the 
genitals of the physicians ; a male patient tried to urinate on 



CLINICAL FORMS 137 

a nurse. During the menses the states of excitement usually 
grow worse. 

While the excitement in many cases only affects the 
patients with a certain restlessness, we meet in others the most 
severe raving mania. .But even in the same case the most 
violent excitement may very rapidly develop from nearly 
complete quiet, and then just as suddenly again dis- 
appear. 

The Behaviour of the patients has only a slight connec- 
tion with their ideas and moods. Anxious patients pray, 
kneel, run off by night, hide away in the forest, try to throttle 
themselves, jump out of the window ; the irritable mood leads 
to sudden deeds of violence, megalomania to the squandering 
and giving away of their goods and chattels, the exalted 
mood to wonderful decorations. A patient, who wished to 
become a poet, copied out Goethe and Schiller with this aim 
in view ; another practised indoor gymnastics " against globus 
hystericus and psychic pains." 

As a rule, however, no satisfactory motive can be found 
for the activities of the patients, which are often extremely 
peculiar ; they seem much rather to follow blindly whatever 
impulses may happen to arise in them. They make aimless 
journeys, want to go to America, run about naked, clear out 
the beds, destroy the stove, burn important papers, smash 
panes of glass, bite to pieces plates and glasses, suddenly fall 
round someone's neck and kiss him, and then spit in his face 
or give him a resounding box on the ear. They drag other 
patients out of bed, strike out senselessly in every direction, 
throw their shoes about, dance about with the door of the 
room which they have lifted off its hinges, gallop away buck- 
jumping in position for fencing, bite a neighbour, shove the 
furniture about the room, take possession of any object with 
blind fury, climb hastily on to a table or on to the window-sill 
in order to defaecate there. A female patient laid small 
pieces of bread in rows on the edge of her bed; kissed the 
grating of the hot-air apparatus for hours, and dragged her 
mattress continually round her in a circle, each time at a 
definite place knocking on the wall ; another stood with arms 
extended on the night-stool ; a third wished to dig up her 
dead father again ; a male patient, when the party was 
gathered together for counting, climbed up a tree, took off 
his clothes, whistled and yodeled. 

Activities. — In more severe excitement the activities of the 
patients are resolved into a disordered series of unconnected 
and unrelated impulses. They dart through the room with 
arms stretched out in front of them, slide on the polished 



138 DEMENTIA PRECOX 

floor, run violently u{) and down or round about in small 
circles so that their track is gradually marked out like that of 
a beast of prey in a cage. Others lie down on their belly 
and carry out swimming movements, glide, roll about on the 
floor, frisk about, hop, stamp with their feet, turn round about 
on their toes, drum with their fingers, throw out their arms, 
grasp ever)'thing round them, creep round, go a few steps 
forward then back again, lift up the beds, bite tight into the 
pillows. At the same time it very commonly comes to 
frequent, rhythmical repetition of the same actions or 
movements. The patients bounce up and down, swing 
hither and thither, clap their hands, make arm movements of 
exorcising, drawing water, fanning, turning, circling ; they 
revolve their fists round each other ; they grind their 
teeth, lift their legs high, turn about, shrug their shoulders, 
throw their hair sometimes over their face, sometimes back- 
wards, blink their eyelids, squint, breathe with forced breaths, 
pant, blow, nod, seize, pull, pick, rub their hands, tap on the 
table. 

Remains of such stereotypies are usually preserved in the 
terminal states. To them are related all kinds of monotonous 
repeated actions which may become habits very difficult to 
root up. Many patients pull their clothes to pieces, bite their 
nails, scrape the lime from the walls, collect rubbish in their 
pockets, tie threads round their fingers or genitals, devour 
buttons and stones, stick objects in their ears, burn themselves 
with their cigar, tear and scratch definite parts. A patient 
perpetually destroyed his shirt buttons in order to bore the 
little metal ring through the lobes of his ears. Here also 
belongs probably the continual spitting which sometimes 
threatens the whole surroundings ; a patient said that he did 
" saliva gymnastics." 

Besides stereotypy we invariably meet in the activities of 
the patients indications of the volitional disorders formerly 
discussed. Automatic obedience is shown in the distractibility 
of the patients ; they weave words they hear into their 
conversation, join in other people's singing, sometimes take 
part in everything that goes on round them. They are 
frequently cataleptic, occasionally also echolalic or echopractic. 
In other patients or at other times negativistic features are 
more in evidence. The patients do not trouble themselves in 
the least about their surroundings, give no answers to 
questions, do not shake hands, do not let themselves be 
influenced in any way in their doings, resist every interference, 
force their way out senselessly, knock or push with their 
knees against the doors. They throw their food away, lie 



CLINICAL FORMS 139 

• 

down in other people's beds, He in a slanting direction, give a 
wrong name, do everything differently from what one expects. 
A patient knocked over the table and then sat down on the top. 

The circumstance that the excitement, even when ex- 
tremely violent, frequently takes place within the smallest 
space, is up to a certain point characteristic of the states here 
described. The patients have not as a rule any tendency to in- 
fluence their surroundings, but their restlessness exhausts itself 
in wholly aimless activity which on this account also needs no 
extended stage. The movements themselves are sometimes 
clumsy and uncouth, sometimes jerky, angular or affected, 
solemn, then again unusually nimble and quick as lightning. 
Side impulses are frequently interpolated. The patients eat 
with the handle of the spoon, give the hand turned the wrong 
way, walk stiffly "as if they were marching tnrough snow," 
lifting their feet high, urinate behind the bed. 

Usually all their actions are carried out with great strength 
and without any consideration, so that it is scarcely possible 
to prevent them. "Go away! I must drag the mattress ; I 
must knock at the door," a female patient cried out ; she gave 
the word of command, " Stand up ! Fall down ! " innumerable 
times, as she let herself fall and got up again. In consequence 
of these doings it sometimes comes to abrasions of enormous 
extent, to more or less serious injuries, as the patient does 
not spare his limbs in the slightest, always knocks the injured 
parts again, and without more ado tears away the bandages 
which hinder him. Not infrequently the patients injure 
themselves in the most serious way. They box their ears 
right and left for hours, dash themselves headlong on the 
floor, try to squeeze in their neck, to tear out their penis, bite 
their arm, tear their hair, scratch themselves, pick at their 
fingers, bruise their tongue and their underlip with their teeth, 
beat themselves on the head, tear out their toe-nails ; a 
patient bit off the tip of his finger. Now and then also 
impulsive attempts at suicide are made. 

The Bodily Care of the patients encounters in these cir- 
cumstances the greatest difficulties. As a rule they are very 
dirty. They pass their motions under them, roll up their 
faeces in balls, devour them, lick up their urine from the floor, 
urinate into the spittoon, smear themselves with menstrual 
blood, put bread in their anus, spit into their hands, into the 
soup, on their bread and butter, in their own bed. They 
sometimes eat greedily, swallowing down their food unchewed 
with haste in incredible quantity, and even taking away their 
neighbours' food ; sometimes they struggle to the utmost 
against the taking of any nourishment, spit everything out 



I40 DEMENTIA PR.CCOX 

again, even what they begged for before with entreaties. 
Many patients only eat when they think they are unobserved, 
or they let the food stand for hours till it has become cold 
and almost uneatable. 

Movements of expression usually undergo very varied 
and singular changes. Here belong spreading gestures, 
making faces, threatening flourishes, senseless shaking and 
nodding of the head, monotonous crying, crowing, yodeling, 
clicking, spitting like a cat, singing, squeaking, screaming in 
falsetto, screeching and growling, and continuous, uncontroll- 
able laughter. Speech is sometimes scanning, rhythmical, 
with wholly perverted intonation, sometimes singing or com- 
manding, sometimes jerky, sometimes in broken sentences. 
Many patients declaim in the high-sounding cadence of the 
actor, hold discourses, preach with lively movements of 
expression and mingling of religious phrases, or they hastily 
bubble over with unintelligible words, sometimes in foreign 
or self-invented speech. Other patients whisper and murmur, 
grunt or scream with all their might. One patient barked 
for hours like a dog. Some patients speak through their 
nose, affectedly, in an intentionally coarse or silly manner, 
like small children, without construction into sentences, in 
infinitives ; they turn the words about, use diminutives 
everywhere. To this are added neologisms, and sought-out 
expressions ; a female patient spoke of " poison blisters." 
The substance of the conversations often shows a high 
degree of incoherence ; the following sentences furnish an 
example of this : 

" But I cannot let myself be made mad and dad. You know I was 
quite mad and perhaps am so still. Whether it is a Lord Grand Duke 
or King and Kaiser — whether it is the voice of the court or who it is. 
The dear God in heaven comes as well and if it is only a dog or a gnat 
— or a little bit of bread. I don't know whether I have a fish in my 
hand or a serpent or what rattles or what walks and stands ; I should 
prefer everything in the world. From below ami above no one can be 
made mad." " My nose belongs now stuffed into Jesus Christ and 
everything twisted round me. They all rattle and mock God. And if 
the dear .Arch-Grand Duke is up there, then those on this side and that 
side mock and ridicule and put sleekness in." 

There are to be noticed here the neologisms, the repeti- 
tion of single exi)ressions, "be made mad," "rattle," "mock," 
the senseless similarities of sound, the lack of all connection 
of ideas in sustained construction, lastly the indications 
of exalted ideas and of morbid feeling. 

Verbigeration. — Lastly the phenomenon, already dis- 
cussed, of verbigeration is very common. Sentences of any 
length, frequently wholly senseless (for example " Gekreuzig- 





CLINICAL FORMS 141 

ter Krex in e Umkrexhaus "), also perhaps single letters are 
repeated for hours and days without interruption in the same, 
often rhythmical, intonation, sometimes screaming, sometimes 
whispering, sometimes even in a definite tune. A female 
patient called out fifty times in succession " Up ! " Some- 
times the patients make slips in speaking or a word heard in 
the surroundings is interpolated ; in this way a sentence may 
gradually undergo changes, the result of which then appears 
after some hours. One can often force the patients to repeat 
their accustomed sentences by saying the beginning to them. 
Thus a quite sensible patient for weeks, on the cue " My 
husband " being given in the middle of a conversation, con- 
tinued the sentence in drawling cadence without hesitation, 
though frequently against her will : 

" My husband is a fine man, a cultured, respected, diligent, honest 
merchant, and 1 am his wife ; my child is an honest child, and we have 
no debts in the town, and we have 2000 marks of honest money, and 
300 marks, these we found. My brothers and sisters are honourable 
brothers and sisters, and my brothers are respected, diligent, esteemed, 
honest men of business, and that is the pure truth." 

To the question why she always repeated this speech, she 
said, "because I am cracked." In other cases the substance 
of the verbigerative speeches shows great variety. In the 
writings of the patients also we meet with disconnectedness 
and incoherence of the substance, and the tendency to 
bewildering desultoriness, to sounding phrases that say 
nothing, endless enumerations, uniform repetitions, to odd 
figures of speech and neologisms. Many patients write non- 
sensical whirligigs and assert that this is a foreign 
language. 

Stupor. — In the further course of the disease states of 
stupor follow the excitement ; somewhat seldomer they 
precede, with or without introductory depression. The 
patients become quiet, shy, monosyllabic, sink into brooding, 
stare fixedly in front of them, stand about in corners, hide 
themselves and creep out of sight, lie idly in bed ; a patient 
lay down " in order meantime just to have a good rest," 
Now and then stupor begins quite suddenly ; the patients 
become mute, rigid in their whole body, sink on to the floor, 
. remain lying in cruciform attitude with closed or widely open 
eyes. All independent volitional expression is silent ; speech, 
the taking of food, intercourse with the surroundings, occupa- 
tion, care for their own needs, cease more or less completely. 

External Influences. — The behaviour of the patients 
towards external influences shows, however, certain differ- 
ences, which indeed are subject to. much variation. They 



142 DEMENTIA PRECOX 

are in general characterized by the predominance either of 
automatic obedience or of negativism. If one will, one may 
accordingly separate out a flaccid and a rigid stupor. In the 
first case we principally observe catalepsy lasting for shorter 
or longer periods, which in such states usually reaches its 
highest development. Echolalia, or even echopraxis, meet us 
also, but more rarely and usually only as passing phases. 
The patients then merely repeat quite mechanically what is 
said to them, or even anything they have picked up by 
chance, in certain circumstances even with closed mouth, or 
join in a song which their neighbours are singing. Related 
to this phenomenon is the constrained answering with an 
association or a jerky movement, standing up and sitting 
down, making faces, a turn of the hand when one calls to 
them. The patients often imitate vivacious gestures made in 
an impressive way in front of them (lifting up the arms, clap- 
ping hands), continue for a considerable time a movement 
stimulated by external influence (beating time, rolling their 
hands round each other). Sometimes they are even seen for 
hours doing everything that some one person does in their 
surroundings, saying everything that he says, walking behind 
him keeping step, dressing and undressing along with him 
and so on. Some patients scream at fixed times ; others 
give the word of command at tube-feeding: " Basin, tube and 
glass utensils, all here, all here, Doctor, feeding," " Mouth 
open," " Tube clean ! " A female patient verbigerated : " Put 
on nightdress, lie .down in bed, bath ! Put on nightdress, 
bath, lie down in bed ! " 

The severe volitional disorder in these states appears very 
distinctly when one asks the patients to show their tongue 
in order to pierce it through with a needle. Although they 
notice the threatening needle and comprehend quite well 
what is before them, they still unhesitatingly stretch out the 
tongue on being asked emphatically to do so. In many 
cases the experiment may be made as often as one likes with 
the same result. The patients make a pitiful face at each 
prick, but are unable to suppress the impulse discharged by 
renewed command or in any other way to withdraw them- 
selves from the threatening injury. 

Rigid shutting up of themselves to all influences from 
their surroundings is more frequent in stupor than heightened 
susceptibility to influence. The patients withdraw them- 
selves, cover themselves up, press their hands against their 
face, hold their handkerchief over their mouth, draw the 
cover over their head ; they give no answer, do not look up 
when spoken to, do not ward off pricks of a needle. Only 



CLINICAL FORMS 



143 



rarely does a very strong stimulus bring about movements 
of evasion, still more rarely an unexpectedly dextrous and 
powerful assault. Also an occasional slight blinking, more 
marked flushing or perspiring of the face, twitching of the 
corners of the mouth on such attempts, bursts of laughter 




Fig. 26. Stuporous patient lying on the edge of the bed. 



when something funny happens, point to the fact that not 
the perception of impressions but the discharge of the corre- 
sponding volitional expressions is disordered. Commands 
are not obeyed or only after very long persuasion or with 
vigorous help. Sometimes one sees here and likewise in the 
few independent volitional expressions of the patients that a 
movement is at first begun correctly, but then suddenly 
interrupted or even turned into its opposite. Now and then 



144 DEMENTIA PRECOX 

the negativistic movements are even set in action by spoken 
commands. It is then not only possible to cause the patient 
to go forward by apparently forcing him back and vice versa, 
but he sits down on the night-stool if he is definitely for- 
bidden to do it, stands still, as soon as he is told to go, lets 
go if he is commanded to hold fast. 

Also in a series of other features the fundamental resist- 
ance to the natural volitional impulses can be distinctly 
recognized. Many patients do not tolerate any clothes or 
shoes, not even a shirt, do not go to bed, stand beside it with 
their arms folded, at night lie down on the floor, under the 
bed, on the outermost edge of the bed, like the patient 
represented in Fig. 26. They put on articles of clothing the 
wrong way, turn the bedclothes about, lie on the bedstead 
and cover themselves with the mattress, lie down in another 
person's bed or at least stretch out their legs over it. Without 
a word they force their way out at a certain door, even if all 
the others are standing open, but do not use the key which 
is put into their hand to open it ; they go backwards if any- 
one approaches them, hide themselves in a corner, put on 
other people's clothes, blindfold themselves, throw their 
petticoats over their head, do not let anything be taken from 
them which they have once taken hold of. 

Sometimes in spite of their immobility otherwise and 
inaccessibility the patients carry out single senseless, often 
rhythmic movements, tap on the table or on paper, pull faces, 
move their fingers as if playing the piano. Some patients do 
not speak a syllable for years or even for decades, or they 
just whisper now and then some detached words, mostly 
incomprehensible ; a patient suddenly said ; " Let me to 
Heaven's ladder," and then was again mute. Sometimes 
these mute patients express themselves by writing in a long- 
winded and incoherent way. Others on great persuasion only 
move their lips, or they give short answers, stick to single 
words, break off in the middle of a word or sentence, begin to 
speak when one goes away, and are silent as soon as one 
turns to them again. Their words are usually brought out 
in a low voice, monotonously, sometimes jerkily. 

The taking of food often encounters the greatest diflficulties. 
The patients sometimes quite suddenly stop eating, and 
cannot be prevailed on in any way to continue the meal, they 
spasmodically clench their teeth, press their lips together, as 
soon as the spoon is brought near. They keep the morsel that 
is put in their mouth there for a long time, do not chew it or 
swallow it, let the soup run out again. Often the patients do 
not eat as long as they are watched, let everything stand for 



CLINICAL FORMS 145 

hours, or only take something secretly. Some patients with 
invincible stubbornness refuse soup, meat, or the food placed 
ready for them, but know how to procure by cunning or by 
force their neighbours' food and devour it with the greatest 
haste; others again only take certain dishes; a ferhale 
patient for days and days called out pitifully and monoton- 
ously : "Choc'lat!" 

Faeces and urine are often retained to the uttermost. The 
patients do not use the water-closet at all, even when they 
are ever so often taken to it, but evacuate immediately 
afterwards on the floor or in bed and do not change their 
position in the slightest to avoid the unpleasant consequences, 
or they remain lying on the full bed-pan. Some patients 
squeeze their urethra spasmodically with their fingers. Their 
saliva is not swallowed, but collects in their mouth and then 
flows down over their chin and clothes or suddenly gushes 
forth like a fountain from the full cheeks. 

In the most severe cases of negativistic stupor the patients 
usually lie in bed completely motionless and dumb. At 
every attempt to change their position all the muscles pass 
into a state of extreme tension and offer the strongest passive 
resistance, a phenomenon which caused Kahlbaum to adopt 
the term "tension-insanity," "catatonia." If one presses 
against their forehead their head springs forward like elastic 
as soon as one lets go ; if one touches the back of the head, 
it endeavours to go backwards against the pressure of the 
finger. If the patient is pushed from the place where he is, 
he resists till he has quite lost his equilibrium and he immedi- 
ately takes up his place again as soon as the force ceases 
to act. The patients are often seen for days, weeks, even 
for many months assuming exactly the same position at the 
same place. They squat, kneel, or lie motionless on the spot 
in a peculiar attitude, like a statue, often rigidly twisted on 
themselves, in knee-elbow position, their chin forced down 
on their breast, their head lifted up free of the pillow or 
hanging down over the edge of the bed, the pillow over their 
face, their legs under the mattress, or the sheet between their • 
teeth, spasmodically grasping with their fingers perhaps an 
old bit of bread, a ball of faeces, a button that has been torn 
off, a wreath of roses. They let themselves be rolled about to 
any extent or even be lifted up in the air like a parcel by any 
part of the body without changing the position of their limbs 
in any way. One of my patients folded her hands spas- 
modically for such a long time that gangrene arose at the 
points of contact ; another knelt for years on the same spot 
till he had to be forcibly kept in bed amid violent struggling 

K 



146 



DEMENTIA PRECOX 




Fig. 27. Contracture of fingers in catal(inia. 







1 %■ 22$. Stuporous patient. 



CLINICAL FORMS 



147 




Fig. 29. 
Expression of face in catatonic stupor (a). 



on account of developing arthritis. A patient sat bent for- 
wards in such a way that 
her nose dipped in the 
soup; another held the left 
thumb always extended, 
the right bent inwards ; a 
third sat with the mouth 
open, the tongue stuck in 
a corner of the mouth. 
Many patients assume a 
fencing attitude; a patient 
continually held his hands 
as if he wanted to box. 
Sometimes contractures 
are developed in the joints 
that are continually bent; 
an example of this is given 
in Fig. 27, which represents 
a patient who for long 
years had held his arms 
pressed against his body 
and his fingers bent. 

In stupor the eyes are 
either closed, as in the patient represented in Fig. 28; if 
anything comes near they 
are tightly closed and the 
eyeballs rolled upwards, or 
they are wide open, staring 
with dilated pupils into the 
distance, never fixing any- 
thing; blepharoplegia takes 
place extremely seldom. The 
forehead is drawn up, fre- 
quently wrinkled ; the ex- 
pression of the face, vacant, 
immobile, like a mask, aston- 
ished, is sometimes reminis- 
cent of the rigid smile of the 
^ginetans. Figs. 29 and 30 
represent the face of the 
same youthful patient at 
different stages of a severe 
catatonic stupor. In the 
former the face shows more 
a dazed, rigid perplexity, in 
the latter that sleepy vacancy 




Fig. 30. 
Expression of face in catatonic stupor {d). 



148 DEMENTIA PRECOX 

which is generally connected, as also here, with catalepsy. 
The lips are often pursed forward like a snout (" Snout- 
cramp"), and show now and then lightning or rhythmic 
twitchings. Grinning, sudden laughter, and making faces are 
frequent. 

Constraint is also noticeable in the gait of the patients. 
Often indeed it is quite impossible to succeed in experiments 
in walking. The patients simply let themselves fall down 
stiffly, as soon as one tries to place them on their feet. In 
other cases they march with extended knees, on tiptoe, on 
the outer edge of the foot, with legs wide apart, with the 
upper part of the body well bent backwards, sliding, frisking 
about, balancing, in short, in any wholly unusual attitude 
which, however, is preserved with all the strength at their 
command in spite of every external influence. A patient 
walked with his face turned backwards ; a female patient 
kept accurately to a seam in the floor and did not let herself 
be pushed to the side. Single movements are stiff, slow, 
forced, as if a certain resistance had to be overcome, or they 
are done jerkily and then often as quick as lightning. 

The states of catatonic excitement and of stupor, which 
are here described, and which are apparently so opposed, are 
obviously very tiearly related to each other clinically, as they 
not only can pass directly the one into the other but are also 
intermingled in the most varied way. The patient who has 
just been senselessly excited may suddenly become mute and 
now lie motionless ; the patient who has been stuporous, 
perhaps for weeks, abruptly begins to utter unintelligible 
screams at the top of his voice, to call out cock-a-doodle-doo, 
to bark, to sing a song in a refined voice. Or he leaps with 
long bounds through the roorn, as quick as lightning unhinges 
somewhere or other a window, gives a neighbour a box on 
the ear, and dashes with tremendous force into another 
patient's bed, and then remains again inaccessible or possibly 
even passes through a longer period of excitement. Such a 
change of state occurs with fair frequency in our patients. 
Very often both excitement and stupor last only a few days 
or weeks, perhaps only a few hours, and then gradually or 
suddenly disappear. But on the other hand also a uniform 
clinical state may continue for months, years, and even 
decades, and be only quite temporarily interrupted by 
remissions or by some other kind of morbid phenomena. 
Especially in stupor that happens not very rarely, while 
catatonic excitement stretching similarly over years belongs, 
one may say, to the exceptional cases. 

The character of the phenomena is in different cases very 



CLINICAL FORMS 149 

varied. Stupor may sometimes only be indicated by 
■ taciturn, repellent drowsy conduct, rising in other cases to 
the suppression of volitional discharge, while excitement 
may fluctuate from slight, silly merriment to the most regard- 
less fury seriously endangering life. We may well regard 
it as a mixture of the phenomena of both states when a 
patient dances about mute and with closed eyes, or lies 
motionless and bawls a street song. Indeed, one may perhaps 
on the whole connect the negativistic admixtures in the 
states of excitement, the inaccessibility and the insuscepti- 
bility to influence, the resistance, the speaking past a subject, 
further the indications of automatic obedience, with the 
admixture of stuporous morbid symptoms. On the other 
hand we observe in stuporous patients frequently enough 
single impulsive actions which are otherwise peculiar to the 
states of excitement. The patients suddenly throw a cup 
across the room, jump up in order to smash a pane of glass, 
to go round the table, to throw themselves then head fore- 
most again into bed and lie there motionless, or they give 
utterance to meaningless sounds or scream, hurrah ! The 
stereotyped movements, which are occasionally observed in 
stupor, fiddling, pulling faces, spitting, might also be regarded 
from the point of view of a mixture with the phenomena 
of excitement. From that, however, not much is gained. 
Essentially it only appears that we everywhere meet the same 
fundamental disorders in the different forms of dementia 
praecox and so also in the catatonic forms, certainly in very 
varied conjunctions, even though the clinical picture may 
appear at first sight ever so divergent. 

Consciousness is for the most part somewhat clouded, 
sometimes even very considerably, in catatonic morbid states, 
especially during their development and at the height of 
acute disorder. The patients appear, it is true, almost always 
to perceive single impressions fairly well, even when one 
cannot prove it at first, but still they usually have only a 
rather indistinct idea of their situation and of the occurrences 
in their surroundings, certainly partly on account of the fact, 
that they are not at all concerned about them and do not 
feel the need to work up their perceptions further. They, 
therefore, often mistake people, do not know where they are, 
but cause surprise not infrequently by knowing the names 
of the nurses or of the other patients, by making a jocular 
remark, by complaining about some occurrence or other, 
by giving a reasonable account of their circumstances, by 
composing a connected letter with an accurate account of 
their place of abode and the request to be taken away. 



I50 DEMENTIA PRECOX 

Many patients also solve arithmetical exercises correctly, 
even of a somewhat difficult kind and display surprising 
knowledge ; an apparently quite obtuse and inaccessible 
country lad could give accurate accounts of the Crusades and 
of Konradin of Hohenstaufen. Quite commonly discernment 
and clearness are much less disordered than one is inclined 
to assume from the singular demeanour of the patients which 
is essentially dependent on volitional disorders. 

Insight. — Even a certain insight into their diseased state 
is frequently present. The patients call their singular doings 
stupidity ; they say that they are just mad. To the question 
whether he was mentally affected, a patient replied, " Yes, of 
course ! If one is sensible, one does not do such things ! " A 
female patient, who displayed catatonic stereotypies of 
movement in the highest degree, said to me, " But I must 
always make such stupid movements ; it is really too silly " ; 
another complained that she always had to make faces, her 
laughing should be driven away. Many lay stress upon the 
fact that when they laugh they do not feel at all merry. A 
satisfactory account of the motives for their singular behaviour 
is certainly never got from the patients. A patient gave as 
the motive of his mutism the answer, " I am not yet suitable 
to be able to show a voice " ; another stated that he had 
given utterance to his thoughts only in writing because he 
could not at once find words ; a third said he had not spoken 
because he knew no one. A female patient said that she had 
not wished to speak, another that she did not venture to 
speak. The physicians had already known everything, the 
questions had been so simple, they had not known what they 
should say, are similar utterances. On being asked the 
motive of her refusing to eat, a patient declared that she 
simply did not need to eat; another asserted that she had not 
been hungry. Usually one is told that the patients were 
obliged to do what they did ; " was obliged to spit " said a 
patient. Another declared that she was obliged to speak so, 
it was given to her so ; a third on being asked why she 
assumed such peculiar attitudes answered, " Because I wish 
to." Similarly a patient declared that he had remained so 
motionless because he had wished it ; another alleged that he 
had been obliged to behave in that way, he had been 
unconscious. It had just amused them, come into their head, 
they had thought it had to be so, a power, an impulse, a force 
had come over them, are answers that frequently recur. 
Automatic obedience is explained by the fact, that it had just 
been wished so, that the patients had thought that they were 
doing the physician a pleasure. 



CLINICAL FORMS 151 

Much more rarely are other motives alleged. A patient 
according to his own account had believed that he would 
apostatize from God if he ate ; a female patient said that God 
had not wished it ; another said that he had been drawn to 
his violent movements " as with a rope," a third who in 
counting always left out the number four, said that he always 
had to think at the same time of the fourth commandment. 
A fourth who for hours played passionately on the mouth- 
harmonica, affirmed that the omnipotence of God inspired 
him to make music in order that the military should take no 
harm. It can be clearly enough recognized from all these 
alleged motives, that the singular actions are of impulsive 
origin and do not depend on definite deliberation. 

In spite of these clear statements about the peculiarity of 
their condition which in general is usually regarded as 
diseased, the patients have, at first at least, no real under- 
standing of the gravity of the disorder. Many patients 
complain bitterly about the treatment which has been 
accorded to them ; an extremely stuporous patient who for 
a full year had sat huddled up in bed, whose sensitiveness to 
pin-pricks had been tested, and whom one had often tried to 
put in a lying position, was enraged after sudden awaking 
from the stupor because she had been thrown into bed and 
that iron bars had been bored into her head. Another 
demanded 30,000 marks damages. To all representations of 
the incomprehensibility and morbidity of their conduct the 
patients give as answer explanations which say nothing, they 
had just not known where they were, were without cause torn 
away from their domesticity, had been treated in quite the 
wrong way ; it was then not to be wondered at, if they had 
become somewhat confused. 

Recollection of the period of the disease appears as a 
rule to be fairly clear, but very imperfect. The patients state 
that it may well be possible that this or that has happened so, 
but they did not know about it, neither could they explain 
how they had behaved as they did. Sometimes they dispute 
some of the occurrences very resolutely; then again assert 
that they have been dead, have been overpowered. The 
intermingling of delusions and hallucinations on the one 
hand, the inaccessibility and lack of insight of the patients on 
the other hand, make it often difficult to obtain a reliable 
account of the real substance of their recollections. The 
indifference, however, with which the patients regard their 
own serious malady is almost always very striking. They 
do not feel any real need to explain to themselves the details 
of their morbid experiences, do not ask about the subject, 



152 DEMENTIA PR/ECOX 

will not listen to anything about it, smile incredulously when 
they arc told about it, do not -attribute any very grave import 
to the disorder ; regard themselves at once as perfectly well, 
as soon as they have become to a certain degree clear and 
quiet, insist without more ado on discharge, blind to better 
counsel. 

Mood in states of stupor usually shows no marked colour- 
ing. Often the patients appear to be in a state of anxious 
tension, so that formerly a section of these cases was named 
"melancholia attonita," as the rigidity was connected with 
emotions of anxiety and fearfulness. It is as a rule easy to 
convince oneself that fear is not the motive of the patients' 
behaviour. They are not influenced by threats, do not draw 
back from the clenched fist or the drawn knife, do not blink 
when the point of a needle is brought near their eye. Only 
in the beginning of the disease do we occasionally notice, 
corresponding to the depressive delusions, outbreaks of 
violent fear and despair. Later the mood changes often 
without recognizable cause ; pitiful weeping gives place to 
furious irritation or childish merriment, while a dull indiffer- 
ence forms the basis, and is expressed particularly in the 
behaviour of the patients to their nearest relatives and in the 
gradual disappearance of wish and will. 

The General Course of the catatonic forms is very varied 
as already appears from the description given. It shapes 
itself in still more changing forms because in about one-third 
of the cases considerable improvement in all morbid 
phenomena, sometimes re.sembling complete recovery or 
coming very near it, occurs, most frequently as it seems in 
* the cases beginning with a state of depression. The duration 
of these periods of improvement varies greatly ; they most 
frequently last about two to three years ; but they sometimes 
last nine, ten, twelve, thirteen, fourteen, sixteen years ; indeed 
once between the first attack of the disease and the second 
which led to dementia, there was an interval of twenty-nine 
years. The objection can certainly always be made, that in 
the case of such long intervals the two attacks have nothing 
at all to do with each other. Meanwhile the observation that 
a pause of ten years' duration between two attacks with quite 
similar morbid phenomena is frequent in this as in other 
forms of dementia praecox, shows there cannot well be any 
doubt here about a long respite and renewed outbreak of 
the same morbid process. But then also we often enough 
see the insidious development of the malady extended over 
long, long years till at last an acute disorder announces the 
real outbreak of the disease. Not altogether seldom the 



CLINICAL FORMS 153 

disease runs its course in three, or still more, attacks separated 
by periods of improvement, attacks which in certain circum- 
stances may at first be of only quite short duration before 
a more serious one commences leading to dementia. The 
individual catatonic states may either follow the one immedi- 
ately after the other and alternate quickly, or be separated 
from each other by long intervals. I observed a case where 
a state of excitement followed the introductory stupor only 
after fifteen years ; in other cases the malady began with a 
state of stupor which was first interrupted by a remission 
of many years and then a characteristic state of excitement 
developed. In another case stupor appeared only after the 
malady had lasted for fifteen years. 

In the terminal states dementia along with the phenomena 
of negativism and mannerisms was in great excess. Simple 
weak-mindedness was the issue in about 1 1 per cent, of the 
cases, dull dementia still somewhat more rarely. Seizures 
were observed in 17 per cent, of the cases. A female patient, 
thirty-one years of age, broke down completely a few days 
after an attack with deep unconsciousness and unilateral 
manifestations of cerebral irritation. On the whole we must 
reckon the catatonic forms with the more unfavourable 
varieties of dementia pra.^cox on account of the frequency 
of profound dementia, while passing improvements are some- 
what more frequent than in the average of the cases here 
taken into account. The share of the men with 54 per cent, 
and of the cases under the age of twenty-five with 57 per 
cent, does not deviate from the average ; still the forms 
beginning with stupor seem to me to begin at a somewhat 
more advanced age. The number of the observed cases 
included 19.5 per cent, of the whole series. 

The Paranoid Dementias. 

A picture, which is in many respects divergent, is 
exhibited by those cases, the essential morbid symptoms of 
which are delusions and hallucinations ; we call them paranoid 
forms.^ I feel justified in including them in th.e domain of 
dementia praecox by the circumstance that in them, sooner 
or later, a series of disorders of a kind which we' everywhere 
find also in the other forms of dementia praecox, invariably 
accompanies the delusions. Further in a large number of 
cases . terminal states are developed, which completely 
resemble the forms described up to now, and also in the 
remaining cases a psychic decline is developed, which in 

^ Ferrarini, Rivista sperimentale di freniatria xxx. 876 ; xxxi. 435. 



154 DEMENTIA PR.ECOX 

spite of many peculiar features, nevertheless discloses a near 
relationship with the issues of dementia praecox already 
known to us. 

Paranoid Dementia Gravis. 

If, as seems conformable to our purpose, we let ourselves 
be guided in the grouping in detail by the point of view of 
prognosis, we shall next have to take into consideration those 
paranoid morbid states, which, it is true, begin with simple 
delusions, in the further course, however, exhibit always more 
distinctly the peculiar disintegration of the psychic life, and in 
especial also the emotional and volitional disorders in the form 
characteristic of dementia praecox ; they might be grouped 
together under the name of " dementia paranoides gravis." 

The development of the disease took place in 6^ per 
cent, of my cases insidiously ; in 17 per cent, of the patients 
there existed from youth upwards certain unfavourable 
peculiarities of character, frivolity, love of pleasure, defiance, 
self-will, unyielding and hasty conduct. Among the women 
there were several prostitutes ; among the men fp per cent, 
were vagrants. In about 30 per cent, of the cases the disease 
began subacutely ; usually it was a case of convicts, who fell 
ill during imprisonment; in 7 per cent, of the cases the 
beginning appeared to be acute. The introductory disorders 
are quite similar to those of the remaining forms of dementia 
praecox, headaches, tiredness, aversion from work, sleepless- 
ness, restlessness, irritability, a changed, monosyllabic, shy 
behaviour. 

Delusions. — Gradually there come " forebodings," " things 
come to light." The patient notices that he is being 
oppressed, too little considered, he is being maligned, 
insulted, scoffed at. The people in the street stop, make 
jokes about him, look at him in a rude way, laugh, make 
insinuations as if he had stolen, as if he were to blame for 
everything. Everywhere there are aiders and abettors ; a 
marriage which he has planned is being prevented ; the 
neighbours are taking everything out of the house, he is 
being plundered and robbed ; secret debts are being made, 
there are people in the warehouse, burglars are breaking 
in ; people are forcing their way into his room. The Jews 
are lying in wait for the patient's children ; his relatives 
want his money ; the parsons spoil everything ; the sermon 
is aimed at him. Newspapers scribble about him ; letters 
are changed and falsified ; everywhere there are rascally 
tricks and Freemason ongoings. 



CLINICAL FORMS 155 

Everything seems changed and uncanny to the patient. 
His children are all confused ; his whole surroundings are 
bewitched and enchanted. The physicians are not right 
physicians, his fellow-patients are suspicious personages ; 
the clock stops ; money has not the security that it once 
had. Every one is being murdered ; everywhere wounded 
men are seen ; his father and brothers and sisters are being 
strangled, roasted ; the Grand Duke is being killed ; the 
patient is in a den of murderers. A female patient thought 
that outside there was the Lake of Constance, and it had 
destroyed all countries and human beings ; a patient said 
that all souls were lost ; in three days there would be the 
last judgment. The patient acquires the conviction that 
he has very powerful enemies and is threatened with frightful 
dangers. People want to behead him, to immure him in the 
stove, to crush him, to burn him, to throw him to wild 
animals ; sparrows, rats, dogs with goats' hoofs are called 
out against him. By the order of the Grand Duke revolvers 
were distributed in the village, he is going to be brought 
before a secret military tribunal, is being treated as a political 
prisoner ; a patient perceived that some one was working 
at her coffin. There is poison in the beer, soap in the 
drinking-water, morphia, hydrochloric acid, iodine in the 
food ; the patient accordingly feels burning in his mouth 
and obstruction ; everywhere " bellephonpoison " and phos- 
phorus are displayed ; the dishes are dirty ; bread is baked 
specially for him by the baker. His enemies, who lie in 
wait for him, are sometimes Freemasons, parsons, the 
** Frankfurter," the devil, " Brother Markus," sometimes the 
nearest relatives, his sister and especially his wife, who speaks 
evil of him and poisons him ; he feels it. She takes sides 
with her brother, with the clergyman. 

Hallucinations usually appear very soon. The patients 
see figures, people with little red caps, black men, cows, 
Christ, angels and saints at the altar, " little figures and little 
souls," God, the Virgin Mary. A patient saw a man in green 
bathing-drawers, who was playing with his penis ; a female 
patient saw her supposed loved one lying on her bed at 
night. By far the most frequent are auditory hallucinations, 
whispering, signals from the air, exclamations, abusive names. 
Voices are heard in the sound of the bell, in the chirping of 
the birds, in the sounds which animals make ; people speak 
about the patient and his wife ; there is whispering and 
ringing in the walls ; at night there is loud talking in the 
room. Sometimes the voices seem to have completely the 
character of real perceptions ; the patient can give their sub- 



156 DEMENTIA PRECOX 

stance in words and also recognize their supposed authoi. 
Thousands of people threaten and abuse him from the wall, 
said a patient ; another stated that he had got his hearing 
from his father and mother ; a third said when he was 
brought to the hospital, " The devils of fellows speak here 
too!" 

In other cases the illusions are more or less sharply dis- 
tinguished from sense-impressions. The patient hears the 
voice of God, invisible beings speak, evil spirits let him have 
no rest, grossly abuse him : he hears all sorts of things " in 
thoughts," has voices for the whole of Europe by the appar- 
atus or current ; " Nature speaks to me," said a patient. The 
voices are referred to different places. " There is something 
in my ears," declared a patient ; another heard " memorial " 
all day long in her head. *' The words have come out of my 
stomach," asserted a male patient, while a female patient 
heard speaking in her genitals, and another thought she had 
a telephone in her feet. 

What the voices say is usually unpleasant ; " If I could 
only get rid of my hearing ! " exclaimed a patient on this 
account. The patient hears everything that one says or 
thinks about him, that he is going to be executed, beheaded, 
that he has committed lese-majeste ; " He is to be got rid of," 
it is said ; there is a war going on. A patient heard " a mur- 
muring," that his brother was dead. Female patients hear 
"immoral stuff"," sexual accusations; forest-whore, married 
man's whore, strolling whore; they have committed abortion, 
killed a child. Sometimes the voices forbid the patients to 
work. A patient heard that he was God. 

Frequently the patients' own thoughts are perceived by 
others. The people know by the voice-telegraph what the 
patient is thinking ; they speak of his thoughts ; what he 
thinks and reads is repeated after him. The patient answers 
silently, speaks with the voices the whole day, converses with 
Kaiser Wilhelm, with spirits, carries on dialogues " on the 
thought-way through the nostrils." Sometimes also the 
thoughts are made ; the patients must think what others 
think ; transference of thought takes place ; " These are 
things, they flow to one, and one says them," said a patient. 

Occasionally also other kinds of hallucinations come under 
observation, the smell of corpses, the taste .of sulphur in the 
food, mephitic air, the feeling of being electrified, pulled at, 
of being doubled. " Something wanders about in a wonder- 
ful way in my body," said a patient ; another felt a machine 
in her teeth and in her breast ; the taking of the temperature 
caused another one pains. A patient had pain in- his heart 



CLINICAL FORMS 157 

when the post drove by ; another complained, " The cover 
smells so loud " ; a third felt " chinks of pain." 

Hypochondriacal Ideas. — In the further course of the 
disease the delusions soon acquire an always more wonderful 
character. In especial there are nonsensical hypochondriacal 
ideas, in which the delusion of persecution finds shape, pos- 
sibly in connection with morbid common sensation. Often 
also the delusions are connected with the experiences of 
dreams, which are without hesitation regarded as reality. 
Blood is drawn off from the patient, it is beaten to milk ; 
something is taken out of his body, his bowels are torn out ; 
everything is sawn to pieces, his face is disfigured, his heart 
is stolen, something is being poured into his throat. A 
patient thought that he was being continually filled with 
water, which he must then pass, and in consequence kept 
running innumerable times to the water-closet. His eyes are 
sprinkled with poison, drawn out of his head ; his sight is 
taken from him ; " something is being done to my fine eyes," 
complained a female patient. His head is closed, pressed 
together, is to be made confused ; the skull-cap is being 
taken off, the central nerve is lacerated and bleeding, the 
nervous system is torn down, the brain is bored through with 
Rontgen rays, the head-power is weakened ; another head 
has been put on. The patient is to be made crazy, giddy ; 
his understanding is stolen, his thoughts are criminally taken 
from him, his four senses are fetched away by the doctor ; he 
is becoming idiotic, a simpleton ; a patient complained that 
he could not stand the things going through his brain. The 
patient feels that he must die ; his blood runs cold, his inside 
is annihilated ; beauty is gone, the freshness of life is lost. 
Something is wanting in his head and spinal marrow; the 
brain is shrinking ; the patient- has no longer any intellectual 
life, any heart ; he must live for ever. 

Sexual Influences usually play a large part in these 
complaints, especially in female patients. At night women 
come ; the patients feel themselves used sexually from 
behind ; their nature is driven off, thrown in their faces. 
Women are tormented by " seductive stories," violated at 
night, turned into whores ; people wish to practise obscenity 
with them. The physician has given them desire in their bath ; 
they feel it sometimes in their back, sometimes in their head, 
sometimes in their hands. At night there are seventeen or 
eighteen gentlemen in their bed ; the hospital is a brothel ; a 
female patient declared that the obscene practices with the 
three and four must now cease. The abdomen has no resist- 
ance, is not right, the periods are hindered ; the motherly 



158 DEMENTIA PR.ECOX 

feelings have been torn out, the maternal parts have been 
turned outside ; the patients feel themselves " made nature- 
less." The womb has never been loved, is rotting, sways 
about in the hinder parts ; the ovary is to be operated on, 
pepper is to be put into the mouth of the uterus. 

The idea of being infliie^tced, constrained, appears distinctly, 
as in the delusions quoted, also in many other utterances. 
The patients are tormented and have their lives threatened 
by machines, by " light-tube-ray-apparatus," by sympathy, 
hypnotism, enchantment and witchcraft. They are influenced 
by artificial means, are changed every day, feel it in their 
body; at night abductions take place. A power drives the 
patient, accumulates, goes right through people, gives a 
ringing tone and overcomes him ; a patient was caused by 
the compulsion, by the " going round of his head," to go twice 
to America. The patient feels intrigues, "mental transferences 
to planet and sun " ; sentiments all run to him ; "intellectual 
patterns are being fitted on." He is caused to have pains in 
his back ; he is being made to scratch his face. Sometimes 
it is the evil eye that brings this to pass ; the physicians speak 
the eye-language ; " But one may not with a look tear out 
ninety years of a lifetime," complained a female patient. " I 
am a depressed body, a fettered human being," said a patient ; 
"lightning things have no aim"; another pleaded that he 
would like to have his rights, his power again. A third felt 
himself in " public, hypnotic custody " in spite of apparent 
freedom in the enlarged cage, as the " hypnotists " had him 
completely under their control by the hypnotic power of 
their eyes. 

Exaltation. — Alongside of the ideas of persecution there 
are present in more than half of the cases exalted ideas ; 
in a small number of cases they alone dominate the clinical 
picture. Usually they appear only after some time, even 
after several years, more rarely towards the beginning 
of the malady ; thus in the case of a postman almost the 
first striking morbid symptom was that he signed himself 
on an official document as General Field Marshal. The 
patient has supernatural gifts, has made important inventions, 
the Rontgen apparatus, the "Peter mobile"; he possesses 
numerous patents, a factory ; the hospital, the country, all 
kingdoms belong to him. He has money in the safe, has 
great riches, is getting a situation with a salary of lOOO 
marks ; he has a claim to thirty-two millions, which have been 
deposited for him by Rothschild and the Shah of Persia ; 
he demands every day looo marks damages, he understands 
the making of money; a patient asserted that he had "the 



CLINICAL FORMS 159 

ransom " as he twisted off all the buttons from his suit and 
attributed to each the value of some thousand marks. The 
patient is prince by the grace of God, heir as German 
Emperor, owner of the German Empire ; ,his father is prince, 
Kaiser ; he was at the age of twenty - five king, having 
inherited from his great-grandfather ; he possesses a privileged 
and triumphal canopy, wants a uniform, wants to live in the 
Castle, wishes to have an explanation from the local magis- 
tracy about his lineage. A patient who was hoarse, thought 
that he had the Emperor Frederick's disease and was there- 
fore related to him and of royal blood. Another is rightful 
successor of the cross as Pharaoh, thought-reader, clairvoyant, 
called of God, born for the salvation of all mankind, Paul, 
God the Father, guardian angel, judge of the quick and the 
dead. He has two natures, a divine and a spiritual, is stand- 
ing already in the red magnificat, must punish the wicked, 
protect the pipus ; he receives revelations, can make the 
sun rise. Many patients tell a story of inner transformations 
which they have experienced and in which their future high 
calling has become clear to them ; a vagrant heard then that 
he was to become an organ-builder. A patient asserted that 
his fiancee had born him spiritually. 

Female patients are Baroness Bergshausen, Planga Geyer 
von Geyersberg, Countess Drossel, Empress of Ladenburg, 
royalties, daughter of Kaiser William I., wife of the Kaiser, 
must take the place of the Kaiserin ; they get maintenance 
from the Kaiser ; they are ruler of the world, queen of 
heaven, lord over all higher things, wish to redeem mankind, 
have the keys of hell. To them belong all kingdoms ; God 
is their dear papa. They speak of their subjects, explain 
that the institution belongs to them, desire to go to a grand 
hotel, to their kingdom, to Berlin. A patient declared that 
she was Christ; another called herself by her husband's 
name, asserted that he was her wife, asked for trousers and 
wished to go out to work on the fields. Many patients do 
not acknowledge their husbands any more, wish to marry 
a baron, travel after a curate, whom they think is their 
husband, ask the physician to marry them. A patient put 
on mourning for her supposed lover; another fell in love 
with the priest, wished to go with him to Rome, where he 
was to become pope ; a third declared that the Kaiser came 
to her every night. 

Memory. — Here and there the delusions are connected 
with errors of memory, which misrepresent to the patients 
experiences of a time long foro^otten, back in their earliest 
youth, indeed from a former existence. The patients think 



i6o DEMENTIA PRECOX 

that they are supposititious children because they do not 
resemble their brothers and sisters ; they remember being 
dandled as children on the knees of the reigning prince in a 
beautiful castle ; later they were badly treated by their 
" foster parents," and heard all sorts of hints from them 
that had reference to their high lineage. A patient asserted 
that he had already lived in the house of his grandparents 
when his parents married, and he remembered the celebra- 
tion of their marriage ; another stated that he had lived 
in America from 1795 to 1820; a third narrated that he 
was born in 1797 and then he grew up in Moscow ; he was 
present at the crucifixion of Christ, had founded Universities, 
built castles, erected the Houses of Parliament, hunted lions 
in Africa, taken part in all campaigns. These cases in which, 
according to the utterances of the patients, the delusion has 
apparently already begun in early childhood, gave Sander 
the occasion for the description of an "idiopathic" paranoia, 
in which the development of the disease was said to extend 
back into childhood. Further experience has meanwhile 
shown that in such narrations it is without exception a case 
of subsequent morbid invention. Neisser has therefore 
frankly put down as the characteristic mark of the group 
circumscribed by Sander, errors of memory and proposed 
the delimitation of a "confabulating paranoia." According 
to my conviction the cases of Sander which have been 
quoted belong to dementia praecox. As a rule the errors of 
memory here form only a passing morbid symptom, .so that 
they are scarcely suitable for the delimitation of another 
group. 

If at the beginning it is in some measure possible to 
follow the patients' train of thought, in the further develop- 
ment of the disease the senselessness and the singularity of 
the mode of expression, which have already frequently 
appeared in the examples quoted, become so pronounced 
that it is scarcely, or no longer at all, possible to make out 
the meaning of the morbid utterances ; neologisms also help 
to make it more difficult. The patients complain about the 
people who carry on murder, the subterranean business of 
human beings about their body ; at night they feel themselves 
drawn out through a needle. The bleaching-book is being 
opened ; the railway has for nine years closed the convict- 
prison ; intellect was brought into high heaven ; a dog's 
trick is being carried on with them ; the central nerve is 
being led off from its origin. They have growth, the murmur- 
ing of the sea, no more breast-food, liver-constriction, white 
dysenteric consumption ; an acceleration course is arranged 



CLINICAL FORMS i6i 

against them. A patient said that he was "the abusive 
epithet empire, his heart certainly and human life"; a female 
patient declared that she bore the globe and the telephone. 

In spite of these often quite incomprehensible utterances, 
the patients are usually permanently clear about their 
residence, about time and about people, even though 
delusional falsifications and wrong interpretations are 
frequently recognizable. Thus a patient thought that she 
was in the confusion-institution ; another called the hospital 
the casemate-convict prison. The patients also often mistake 
the physicians and their fellow-patients and they disown 
their own relatives, but not on account of real disorders of 
perception, but in connection with delusions. Consciousness, 
apart from passing states of excitement, is not clouded; the 
patients are sensible and perceive fairly well, are able to give 
an account of their circumstances, and to solve the more 
simple intellectual exercises, so far as they are not hindered 
in doing so by volitional disorders or by increasing dementia. 
Of understanding of the disease on the other hand there is 
no question. The patients at most admit that through the 
persecutions they have become somewhat " nervous." " To 
mention in one word myself and the madhouse is just 
exactly a quadratic perversity," wrote a patient. Nor does 
ocular evidence convince the patients. If they are taken to 
the room where they suppose that the persecutors are, they 
only acknowledge that everything suspicious has meantime 
been cleared away. 

Mood shows no very pronounced colouring. Many 
patients exhibit greatly increased self-consciousness or silly 
merriment ; frequentl y one sees them breaki ng out into cause- 
less laughter? Utliers appear remarkably mditierent and 
Unconcerned . But very frequentTy there is repellent , i rritable, 
quarrelsome behaviou r with occasional violent outbursts ol _ 

*abuse, and e ven acts of violence , especially at the time of the 
menses. Sometimes a state of very lively sexual excitement 
appears, which expresses itself in regardless masturbation, 
obscene talk, coarse proposals and assaults. A female 
patient continually begged in the most urgent way to be 
examined with the metroscope ; another stuffed horsehair 
into her vagina. 

The Activities of the patients seem to have some relation 
to their delusions but they usually bear the stamp of 
singularity and incomprehensibility . The ideas of persecu- 
tion lead to vi olent outbursts oi rage and dangerous attacks 

""on fHe supposeH enemies. 1\ patient threatened the 
clergyman that he would shoot him ; another locked in his 

L 



i62 DEMENTIA PR/ECOX 

wife and children and handed over the key to the public 
prosecutor for further enquiry. A female patient wished to 
cut her father's throat, another suffocated her friend, a third 
wished to kill herself and her child because she had heard 
"perdition take her and her brood!"; a fourth hit her 
husband on his head with an axe "in order to redeem him." 
The motiv es of these attacks are often ve ry obscure. A 
patient telt himself suddenly lorced to injure his sisier with 
whom he was on good terms, went up to her on the road and 
stabbed her in the back. Not infrequently the patients apply 
to the authorities to complain about the persecutions and to 
ask for help, sometimes in wholly confused documents. The 
hallucinations cause the patients to stop their ears or to beat 
their ears ; two of my patients in this way brought on them- 
selves haimatomata auris. Others speak away to themselves, 
answer the voices, call into the heating apparatus, become 
restless at night in order to defend themselves from 
reproaches and abusive language. Ideas of poisoning may 
lead to refusal of food ; a female patient for a considerable 
time only ate eggs ; one patient only drank milk ; another 
spat a great deal in order to get rid of the poison again. 
Many patients suddenly fling their food away, because it 
appears suspicious to them. A patient tied herself up wholly 
in cloths in order to protect herself from the influences which 
she feared. Occasionally it comes also to attempts at 
suicide ; a patient tried to remove his testicles by ligature ; 
a female patient swallowed needles. 

Exalted ideas connected with religion lead to the declaim- 
ing of texts from the Bible, to preaching and fasting, to 
abuse of the clergy ; a patient built for himself a house altar. 
Here also the taking of food is often involved. A female 
patient took only bread and water ; a patient fasted on 
Thursday and Friday ; another thought that a higher being 
did not require to eat at all, nor to ease himself. A female 
patient went to the local medical officer and asked him to 
cut open her back and fix in angels' wings. Sexual excite- 
ment causes the patients to commit dissolute acts, to decide 
to be divorced, to make an attempt to approach any wholly 
unknown person whatever of the opposite sex, and to commit 
immoral acts on children. A female patient wished to marry 
her brother. 

Alongside of these volitional expressions, which after all 
are still to a certain exttent comprehensible, go others for 
which intelligible motives can scarcely be discovered. The 
patients wander through the house at night ; they suddenly 
stoj) the alarum clock, tear out stakes from the vineyard, 



CLINICAL FORMS 163 

tear down the vines, search in the graveyard for the grave 
of their wife who is still alive, run to the water-closet a 
hundred times in the day, cut off their hair. Sometimes here 
also delusions may play a part to which the patients do not 
give expression ; but often we have certainly to do with 
purely impulsive actions, about the origin of which the 
patients themselves are not able to give any exact account. 
This view appears certain in the numerous actions which we 
have come across in quite similar form in the types of 
dementia praicox previously discussed and which we have 
there learned to recognize as the result of the volitional 
disorders peculiar to this disease. 

Negativism. — Next we meet with a series of negativistic 
phenomena. The patients are repellent, inaccessibl e, mono- 
syllabj c, even mute, withdraw themse lves, hide themselves 
away, draw the clrover over their hea3. One patient gave 
utterance to his thoughts only in writing ; others only answer 
in indefinite phrases or speak past the subject. They do not 
shake hands because they " do not need to," " may not do it," 
because they " do not any longer go in for frivolity." Or 
they give the left hand, the finger-tips, or wrap up their hand 
in their handkerchief Many patients keep their eyes closed, 
cover their mouth with their hand, lie down in other people's 
beds, refuse food at times without recognizable cause, now 
and then pass their excreta under them ; if told to employ 
themselves, they refuse. On the other hand the patients 
occasionally again exhibit automatic obedience, are cataleptic, 
put out their tongue non-voluntarily to be pierced through, 
imitate what is called out to them or done in front of them. 
Often *they are seen assuming singular attitudes, standing 
the whole day on one spot, staring in front of them. 

Mannerisms are often a marked feature. The patients 
pull faces, stick out their lips like a snout, suck their fingers, 
make peculiar gestures, which sometimes appear to represent 
a kind of sign- language, move affectedly, adorn themselves 
tastelessly, put their bedclothes together in a singular 
manner, let down their hair, spit, click their tongue, cut their 
words when they speak, speak rhythmically, in affected High 
German, in a Frenchified style. Among these are inter- 
polated all kinds of senseless impulsive actions. The patients 
pull out the hair of their beard, turn about their own axis, 
suddenly climb right up the window, smash panes of glass, 
throw the dishes about the room, f/ Stereotypies, pulling at 
their fingers, rocking movements, runnmg round m circles, 
'mbnotonous 'movements of arm and hand, rhyming, verbi- 
geration are also frequent. 



i64 DEMENTIA PRECOX 

Speech. — The substance of expression in speech is 
incoherent, odd, exhibits drivelling verbosity, a tendency to 
sounding phrases, quotations, silly plays on words, neologisms, 
sometimes going on to complete confusion. The whole 
manner of speech of the patients becomes in this way, 
especially in the later periods of the disease, extremely 
peculiar, and bristles with bewildering turns of expression. 
A female patient described herself as being ill-treated "churl- 
wise," " horrorwise," " pretensionwise," and as being an 
"embezzled mama"; a patient called himself the "artificially 
opposed person " ; another asserted that the physicians were 
" reversed doctors." " Live without liver has been telegraphed 
to me," said a patient ; a second said " When one gives any 
one the hand, one is love" ; a third received me with the 
words, "I believe that the gentlemen are there for my 
confidence and not for yours." " Doctorship is being made 
with me," complained a female patient, while another on 
being asked about hallucinations, replied : " The attache 
affair has been finished for two years." Again another 
expressed herself, " Personal right does belong to me, a man 
who steps in for me; the avertor must avert," and a patient 
dismissed me with the words, " Are you a state model ? 
Radius, radius, that's enough." Complete agrammatism, 
inability to form grammatical sentences, also occurs ; a 
patient replied to me when I spoke to him : " Sleeping and 
dreaming and emotional state without sympathy and without 
master-key." In the patients' writings similar oddities again 
occur : at the same time we often meet here a singular 
arrangement of lines and letters and queer orthogj;aphy. 
These disorders of the expression of speech in word and 
writing agree perfectly with those which we have an 
opportunity of watching in the terminal stages of other 
forms of dementia prsecox. 

Course. — In another direction also the issues of this group 
correspond completely with those of the clinical types 
hitherto discussed. As terminal state the most frequent 
is manneristic dementia, somewhat seldomer negativistic or 
drivelling dementia. Only in about 12 per cent, of the cases 
simple weak-mindedness is developed without other more 
.striking morbid residua ; just as often dull dementia sets in. 
I could not verify any essential improvements with later 
relapse among my cases, which embrace rather more than 
9 per cent, of all the cases of dementia pr.xcox ; there were 
seizures in only 3 per cent, of the patients. The form here 
described belongs accordingly to the less favourable varieties, 
Its course is essentially more chronic and more monotonous 



CLINICAL FORMS 165 

than any we have hitherto seen ; remissions of the morbid 
phenomena, as well as seizures which may well be interpreted 
as specially violent expressions of the disease, disappear 
almost completely. The fact is very remarkable, that here 
the male sex with 44 per cent, remains considerably below 
the average, but especially that only 26 per cent, of our 
patients were below twenty-five years of age. This paranoid 
form is therefore by preference a disease of middle and later 
life ; a few cases occurred in the sixth decade of life. We 
call to mind here that depressive dementia with delusions, 
which shows many points of contact with this form, also 
shows a certain preference for riper years. If progressive 
experience confirms our present assumption, that in all the 
clinical pictures here separated from one another, it is still 
a case of the same morbid process, one might suppose that 
with more advanced age in itself, the tendency to more pro- 
nounced delusions grows, while at the same time the possi- 
bility of a more complete disappearance of the disorders 
decreases and the course becomes more gradual. That 
delusional forms of disease usually belong in general more 
to riper age is confirmed by many experiences. Also in 
paralysis we see that the forms, which occur in youth, 
generate delusions with considerably less frequency. 

Paranoid Dementia Mitis. 

As a further form of paranoid dementia praecox I think 
that I should now add another group of cases, which on the 
one hand exhibit a quite similar development and the same 
delusions as the paranoid diseases just described, but on the 
other hand result in peculiar states of weak-mindedness. 
While there in the terminal states principally the volitional 
disorders and the incoherence of the original clinical picture 
remain behind, here we have to do with the development of 
a psychic decline which is specially characterized by the 
continuance of delusions or hallucinations ; the issue of the 
malady is a state which we may c^.\\ paranoid or hallucinatory 
weak-mindedness. As here the substance of the personality 
seems to be less seriously damaged, it is perhaps allowable 
to speak of a " dementia paranoides mitis." 

The beginning of the disease was in 74 per cent, of my 
cases slowly progressive, while about 9 per cent, set in 
acutely, the rest subacutely. But certainly also in these 
last cases slighter changes had frequently for a considerable 
time preceded the actual onset. Almost always indeed it was 
a case here of the outbreak of morbid phenomena during 



i66 DEMENTIA PRECOX 

imprisonment in individuals who already years ago had fallen 
into a career of crime, sometimes after good development in 
the beginning, but often also on the foundation of a disposi- 
tion unfavourable from the first or a neglected education. In 
20 per cent, of the cases the patients had shown mediocre or 
poor endowment at school ; some were described as from 
youth up stubborn, self-willed, wicked, suspicious, peculiar, 
" nervous.'" Among the men two-thirds were vagrants and 
criminals, probably a sign that we had here to do either with 
individuals of inferior disposition, or, what for many cases 
seemed to be the more correct view, with a very gradual 
change which reached far back into the past and which only 
after a considerable number of years acquired marked morbid 
features. In all these directions, therefore, the form here 
treated behaves quite like the other. 

Hallucinations and Ideas of Persecution. — The first 
manifestations of the disease also seem to be the same, as far 
as they can at all be verified in the usually very slow develop- 
ment. The patients become suspicious, irritable, insubordin- 
ate, at times threatening and violent, behave in a conspicuous 
way, carry on singular conversations, often change their situa- 
tions, stop working. Little by little it then becomes clear 
that they are suffering from hallucinations, generally auditory, 
and from ideas of persecution. In the cases which set in 
acutely, especially during imprisonment, these disorders are 
usually the first striking morbid symptoms. 

The substance of the hallucinations is mostly hostile, 
provocative. In the beginning there is perhaps only a buzz- 
ing, ringing, humming ; but then the patient hears how he is 
mocked and abused by his neighbour ; he is called bastard, 
rogue, dirty dog, prison thief, wild swine, shabby beast, young 
swine ; they are " voices of persecution." Frequently im- 
moral things are said. The patient hears indecent talk about 
himself; he is said to have assaulted his children criminally ; 
" bigamy " is called out. Women are abused as " princes' 
prostitute, rose prostitute, princes' drabs " ; a patient heard 
ladies' voices which called out to him that he was to come and 
love them ; another was called " pencil-sharpener " (onanist) 
More rarely it says, " He's a pretty boy, a handsome fellow.' 
Sometimes everything that the patient does is discussed : 
" every now and then he peeps again." The master of the 
house telegraphs what he says ; the voices hear everything 
know his thoughts, say them aloud beforehand, repeat aloud 
what he reads; there is thought-reading, double speech. A 
patient thought that two people saw through his ej'es every- 
thing that happened. 



CLINICAL FORMS 167 

But he also can read the thoughts of others, feels what 
people intend to do with him. The voices are sometimes 
quite transcendental, " secret voices," " inward voices," 
" thought brooding," inspirations from above, sometimes 
whispering, "whispering to him," "inblowings," "murmuring." 
People speak through air-shafts, from the clock or through a 
phonograph, sing into his ears ; people over him and above 
him speak (" Roof-runners," " Behind-wallers ") ; from all sides 
there is telephoning ; the patient " is in touch with everyone " ; 
someone is sitting in his left ear. Now and then it is God or 
Christ who speaks. The voices often control the patient 
continuously, especially in the night, the attendants have him 
at night on his trial ; it is a " nightly cross-examination." 

Visual hallucinations are more rare. The patient is being 
dazzled and reflected ; he sees a shining light in the room, 
bright squares, lines, pictures of saints in the sky, a cross 
and the Saviour, the ascension of Jesus in the firmament ; 
" That does not happen to everyone," added a patient. 
Others see " pictures produced as if for entertainment," black 
figures ; a patient asserted that he saw everything through 
glasses in the wall. With these are associated putrid smells, 
a "colossal smell of phosphorus," stinking vapours, bitterness 
in mouth and nose, the taste of petroleum, bugs, chloride of 
lime, human faeces, sulphur, oil, spirit, onion juice, white-lead, 
pepper, poison of all kinds in his food ; he feels sick after 
taking the milk ; the beer is blood-water. 

Dysaesthesiae. — If it is already in such utterances of the 
patients often difficult to decide, whether it has to do with 
real hallucinations or not, it is in still higher degree the 
case in the manifold dysaesthesiae of which they habitually 
complain. They have stitches in the lung, feel themselves 
"embraced by cold," have a sensation of burning and stirring 
in their stomach, cold in their lung, oppression in their heart. 
There is pricking, punching and cutting. The skin itches, is 
too narrow ; their hinder parts are gone so that they cannot 
sit ; they cannot take a deep breath, have no longer any 
lungs ; their brain is running to pieces ; filth is running out 
at their ears. Very soon these sensations are connected with 
external influences and insanely worked up. The patient is 
worried day and night, tormented, burnt, made filthy, ruined 
in his health ; he is tortured in every part of his body. His 
blood is drawn from his nose and body ; saliva is squirted 
into his face and mouth ; he is infected with diphtheria ; he 
is given an enema " of churchyard putrefaction," dangerous 
medicines are introduced into him by little tubes, pulverized 
sublimate is put in his eye ; his ears and head are blown up ; he 



i6S DEMENTIA PR^ECOX 

is burnt with machines ; he is shot in the ears with 5000 small 
shot, electric shocks are |,nven to him ; a hundred mice run 
over his back. His flesh is torn off, taken from his shoulders 
with a magnet ; he is " damaged " ; his heart is sewed up, his 
throat pressed together ; the urinal is fixed in ; his throat is 
made raw ; his face old. His foot is being cut up, his buttocks 
torn ; his veins are being laid hold of and cut through, his 
teeth are being destroyed. Children are boring round about 
his buttocks ; his bowels are being " wound up and deposited 
in plates" ; fieces are pumped up into his brain; his "sex is 
drawn out horizontally and put in again vertically." There 
is a magnet in his ear, wheelwork in his breast, that moves 
him like a jointed doll. The clergyman has pressed out his 
brain by the nose; the patient is "filled up and filled in," 
must breathe in mice and cats ; alternating currents come 
undulating towards him ; there is a " current-war." Often 
these torments are given special names; "filthy murder" is 
being practised, " urine magic " is being carried on ; the 
patients speak of twitching of the fingers, swelling of the flesh, 
.stanching of blood and letting blood flow, event-making, 
bomb-bursting, lobster-cracking, and so on. A patient wrote 
that in him " hallucinizations, alienations, exstirpations, in- 
formations, transversalism, orthotroph)', and so on " were 
being aimed at. 

Besides the extraordinary forms of the dyssesthesicX, the 
circumstance that the tortures are often referred to the time 
of sleep, is also favourable to the interpretation that every- 
where here it is a case more of delusions than of erroneous 
perception. The bed is moving ; the patient is tormented at 
night by blows in the ribs and electrification ; in sleep his 
breast is pressed in, or his bones are taken out of him and 
replaced by sticks. At night "spiritual underselling" takes 
place; there is " much coming and going"; "at night one 
does not have night rest," said a patient. Here it may some- 
times be a case of the interpretation of dreams as the patients 
frequently without any hesitation transfer dream experiences 
to reality. 

Varied Persecutions- — All other possible ideas of 
persecution also make their appearance. The patient is being 
made a fool of, everywhere announced already beforehand, 
watched and persecuted by policemen, tempted by Satan, is 
lost, infected, outlawed, is to be ruined, condemned to death, 
shot, chloroformed, strangled, got rid of, executed, must die in 
May, will be buried in an unconsecrated churchyard. He is 
being cheated, robbed ; people force their way in with false 
keys, spoil his food for him ; holes are being bored in the 



CLINICAL FORMS 169 

roof; cart-grease, chloride of lime, soap is being thrown down. 
Letters are falsified, suppressed ; lottery-tickets disappear ; 
political intrigues are taking place ; justice is being 
administered. The clergyman preaches false doctrine; in 
the newspaper there are allusions ; " people understand it 
already," said a patient. The questions addressed to him are 
'•puzzles"; the people round him are females, "masked"; 
a conspiracy exists in which the accomplices relieve each 
other. There are uncanny ongoings in the house, like a plot, 
a " double world " ; everything is enchanted ; even the cat 
is instigated to breathe on the patients. His wife is dead, 
estranged by witches' sympathy, killed by the doctor ; his son 
is ripped up, hung, his daughter burned ; his children have a 
knife in their neck, have got into the subterranean regions ; 
in the house patients are being slaughtered and worked up 
into sausages. 

Sexual delusions are very frequent. The patients are 
jealous, think that they are married elsewhere; the children 
are not theirs ; a female patient thought that her husband had 
fifty-four wives and fifty-four children. The patient's wife puts 
menstrual blood in the food ; a female who can make herself 
invisible persecutes the patient. Immoral plays are being 
represented ; figures of little girls appear and excite the 
patient sexually ; he is irritated by unchaste talk. Female 
patients are said to be misused, made pregnant by magnetic- 
electrical methods ; men lie in wait for them ; at night filthy 
fellows work about them ; there is match-making going on. 
Filthy deeds are being carried out ; the penis is being tickled, 
rubbed off; the semen poured off, nature drawn off. A 
patient was invited by voices to associate sexually as stallion 
with the daughters in better-class families. 

Sometimes Polish Jews, the clergyman, a former sweet- 
heart, the secret Fj-eemason association, the neighbours, the 
magicians in the subterranean vault, the sister-in-law, the 
overseer in the prison are regarded as the originators of the 
persecutions ; a patient thought there was " a nightly, 
religious, secret, assassinatory, governmental, civil war." As 
means used by their persecutors the patients suppose 
apparatus, an electric death-dealing current, a " patent 
electrifying apparatus," with which also they occasionally see 
someone occupying himself, 300 machines and a patented 
large clockwork which moves everything ; " with electricity 
much can be done " ; there are two souls who electrify the 
patient. He feels himself " full of galvanization," is being 
tormented by the machine, " telegraphed through," examined 
by Rontgen rays ; there are physical experiments, pestilential, 



I70 DEMENTIA PRECOX 

or, it is enchantment, witchcraft. A patient thought that the 
passers-by drew blood out of his body by means of an 
instrument like a cupping-glass which they had in their 
mouths. 

Influence. — The description of influence on thoughts and 
on volition usually play a special part also jn the complaints 
of these patients. " Thronging of thoughts " takes place ; 
the "thought-examiner" exercises an influence; "the apparatus 
causes laughing, crying, cold, trembling, sensations in the 
body." The vehmgcricht causes tensions ; the patient feels 
himself" forced back," "confined," depressed, "in all relations 
disturbed," he is "excommunicated " ; it comes to "criminal 
oppressions and inquisitions." He is worked on by thoughts; 
he must do what the voices command, is pressed to certain 
actions by suggestion. His body is like a machine which is 
made to speak ; his tongue is guided for him ; " They loosen 
the tongue for me, and one must speak, whether one will or 
not." In the involuntary making of a mistake in writing 
a word, " the probability of inspiration prevails." The spirits 
hinder the patient at work ; his thoughts are taken out of his 
head, so that he cannot think anything. Or thoughts are 
given to him which are not his own ; the imputation is made 
to him as if he imagined himself a king. Then again he is 
stupefied, hypnotized, put into a magnetic sleep, must give 
information. A patient was instructed to pull out his hair ; 
" That continues working till I do it," he explained. States 
of excitement, flow of saliva are caused in the patient ; he is 
secretly examined medically by magnetic influence, made 
crazy ; his whole understanding is being destroyed. With 
this he feels rays in his lips ; the voices penetrate to his 
bones. A patient addressed a letter to us "concerning 
spiritualistic conditions," in which he begged for our medical 
help. It said here: — » 

" The above-mentioned spiritualistic conditions of my person consist 
in a real speaking with souls in the inside of my head. Their thought- 
disturbing influence is imposed on me by the mystical-beings mentioned, 
in a compulsory way by boring and piercing, continual itching in my 
head in a way not to be described. I call this ill-usage by souls 
compulsory, as a man cannot ward off from himself their contravening 
influences in the inside of his body. This disturbance frequently so 
severe often passes into a state in which a man does not know at all any 
longer what he is doing. It appears to me that I am performing an 
action which is exactly the opposite of what I ought to do. I regret 
having become a victim of a spiritualistic seizure. Displeasure shown 
not to wish to speak with souls remains ineffectual. I beg to be allowed 
to apply with confidence to the hospital in order to be able to hope for 
final relief in the conditions of disturbed soul." 



CLINICAL FORMS 171 

Besides the auditory and sensory illusions the painful 
constraint of the patient appears here clearly, which goes 
as far as the reversal of volitional impulses, further the feeling 
of morbidity and of the need for help, without, however, any 
clear understanding of the real character of the malady. 

Exaltation. — In nearly half of the cases there are also 
exalted ideas, sometimes appearing at the beginning, some- 
times first at a later period. The patients are not the 
children of their parents, they are of noble birth, related to 
the Kaiser, son of the Emperor Nikolas, daughter of the 
Grand Duchess, of the King of the Suabians, " put in the 
world by the Grand Duke by command of the Kaiser," have 
a claim to the throne of Bavaria ; a patient asserted that he 
was 135 years old and had been a volunteer with a red 
uniform for one year in Russia. Female patients are a 
former queen, Countess Salm, Baroness von Lichtenstein. 
The Emperor Frederick has visited them, made their son 
minister; the Duke of Coburg has given them lottery-tickets; 
they are going to the Grand Duke and to the Kaiser at 
Berlin, and are waiting for the carriage which is to fetch 
them. Other patients have got an inheritance from America, 
millions, several billions are deposited for them; they are 
supported by rich people, do not need to work any more ; 
a female patient thought that her husband had renounced 
seven millions in order to be able to marry her. Others again 
have made great inventions, built the dirigible air-balloon, 
possess currents with which they influence other people, can 
see into the sun, know what will happen next day, are 
" Dr of Industry," sinless. A patient connected a dissolution 
of the Reichstag with a letter written by him to the Emperor 
and thought he found an allusion in the words of the Bible, 
"The city lieth foursquare" to his town, Mannheim; a female 
patient asserted that she had been operated on and had got 
a rectum "of silver foam." Secret relations to persons of 
the other sex are very frequent. The patient is "thrown 
together" with highly-placed persons at night, hears the 
voice of his fiancee who invites him to sexual intercourse ; 
the Empress is presented to him " with charming speeches." 
Female patients recognize in some man or other their dis- 
guised fiance, to whom they give themselves without 
hesitation, and whom they love " with their whole heart " ; 
it is the Baron "Josa von Bolza." They were married 
very many years ago to Prince William; the Prince Regent 
will bring them to the throne ; the physician is their Prince 
Consort. 

Consciousness seems unclouded during the whole course 



172 DEMENTIA PR^^COX 

of the disease. So far as delusions do not come into account, 
the patients are permanently clear about their place of 
residence, the reckoning of time, the persons in their sur- 
roundings and their situation in general. 

Mood is very variously coloured. At first the patients 
are usually depressed, suspicious, irritable, quarrelsome, at 
times very excited, inclined to immoderate outbursts of abuse 
and even to deeds of violence ; some make impulsive 
attempts at suicide, throw themselves into water, or out at 
the window. Later the patients become as a rule duller and 
more indifferent, even though occasionally they may still 
become very violent. Many patients exhibit a cheerful, self- 
conscious mood, make all sorts of jokes, laugh and simper. 

^^^^ Onanism isMiot rare. 

r^^^H The Activities of the 

^^ ^^^1 patients are partly influenced 

^^^ '^^^ by their delusions. They 

complain to the police about 
the persecutions, bring their 
complaint before the court, 
write innumerable letters to 
the authorities, compose com- 
prehensive documents, ask 
for testimonials, health certi- 
i*'K; 31- ficates; a woman went to the 

stopper for nose of a paranoid patient. . . j . i . 

'^^ f r court m order to be present 

at her trial for divorce which she thought was taking place 
there. Other patients search through the house for perse- 
cutors, stop up the keyholes, abruptly leave the house to 
wander about without a plan, cease working. A patient asked 
the supposed father of his child to pay him board, and locked 
his wife out of the house. A woman wanted to kill her 
husband and children; a man beat his wife on her head with 
a hammer. The patients try to protect themselves from the 
voices by stopping up their ears ; a patient had a stopper for 
his nose made with fine holes for breathing, which is repro- 
duced in Fig. 31, in order in this way to prevent the injection 
of saliva and the drawing out of blood. 

The patients try to keep off from themselves hostile 
poisoned arrows and flashes of light by large screens and 
masks. A patient surrounded his whole bed with wires on 
which he hung up in great number phallic amulets. Merklin 
has described a patient who for his protection wore armour 
made of old metalware, which weighed twelve kilograms. 
Another had himself limited the movements of his arms by 
a leather-belt with loops in Order to be able to resist the 




CLINICAL FORMS 173 

impulse to scratch his face, an impulse which was caused by 
his enemies. Many patients try to protect themselves from 
the influences by peculiar gestures, defensive movements, 
definite, often very intricate, attitudes, low continual repetition 
of certain words. Others apply to the public, vent their anger 
by means of advertisements in the newspapers, wall posters, 
open letters, pamphlets,^ or they undertake some or other 
very conspicuous course of action in order to attract general 
attention to their situation. The patients often hope to be 
able to withdraw themselves from the persecutions by frequent 
change of situation and dwelling-place. A patient crossed 
the French frontier in order to see if the currents could reach 
him there also; when he had convinced himself that they 
could, all he wished for further, was to go across the sea, 
although on account of the cable he cherished little hope of 
escaping in this way ; should this means also fail, he was 
determined to kill himself 

Conduct. — The general conduct of life of the patients is 
invariably influenced to a considerable degree by their 
malady. Many are impelled to enter the path of crime 
(theft, indecent assault) or vagrancy ; they wander restlessly 
about, are not capable of any regular work, neglect themselves 
and come down in the world. Others whose lives are better 
protected, can keep themselves, it is true, for a longer time in 
freedom without too far overstepping the bounds of decorum, 
but still show some or other of the peculiarities which are 
known to us as accompanying phenomena of dementia pra:;cox, 
catalepsy, echolalia, echopraxis, frequent negativism, but 
above everything mannerisms and impulsive actions. 

The patients are often inaccessible, repellent, mute, refuse 
the visits of their nearest relatives ; " that's got no aim." 
They answer questions with counter-questions, with the 
remark that one knows already everything oneself, curtly 
deny all morbid phenomena, do not enter into any conversa- 
tion, do not associate with anyone, hide themselves away 
under the cover, refuse food or at least special kinds of food, do 
not shake hands ; " that's of no use." Other patients exhibit 
a peculiar, affected behaviour, kneel the whole night through, 
laugh without occasion, spit round about themselves, have a 
different reckoning of time, fast on Sunday because it is 
Friday, suddenly cut off their hair, smash panes of glass, 
throw the dishes about the room. Many patients are restless 
at night, carry on loud soliloquies, use violent language about 

^ WoUny, tjber Telepathic, 1888 ; Sammlung von Aktenslucken, 1888 ; 
TefFer, Uber die Tatsache des psycho-sexualen Kontaktes oder die actio in 
Distans. 1891 ; Schreber, Denkwiirdigkeiten eines Nervenkranken, 1903. 



174 DEMENTIA PRECOX 

the persecutions, sing songs because it occurs to them to 
do so. 

Conversation. — Very commonly the conversation of the 
patients bears a pecuHar stamp. The manner of speech is 
frequently affected, sought-out High German, interspersed 
with foreign words, unusual turns of speech, odd expressions. 
Man\' patients are very loquacious, and in a longer conversa- 
tion produce a veritable throng of incomprehensible and un- 
connected utterances, although they are able to give quite clear 
and reasonable information if they are asked definite questions. 
Neologisms play a great part, especially in the description of 
the manifold persecutions. The patients are " ilisiert," 
" tupiert," "desanimiert," " anstimuliert," gone to sleep, 
weakened, revenged, jeered at ; " impulse is placed on in- 



Specimen of writing 5. Writing of a paranoid patient. 

stinct"; everything is placed fullof'Isi," bepovvdered with 
" turmalin," the house is " verdreieidigt." They are tormented 
by " Hineinzahmen," " Befeinigen," by " Stigmatisie and 
Hypnotisie," by " Introchieeii," " Veneriepocken " ; they are 
in an "epileptic Bengalese convict-prison." A patient spoke 
of "steel-chip-pin-sausages" and called his persecutors 
"electric assassin-homicide-rivercommissionbusiness-stinking 
he-goats.'' 

Writing. — The documents also which are sometimes 
very numerous and monotonous, exhibit in their singular 
flourishes and their often scarcely intelligible spelling the 
most remarkable derailments of the movements of expression. 
I insert here two specimens of writing of a shoemaker, 
which were written at an interval of seven months. He 
sought out in the newspaper all possible expressions from 
foreign languages, and wove them in with a meaning invented 
by himself in his decree as "heavenly physician, astronomer 
and President Lichtenstern." In the second there are the 
words " Fidelis Syphilis," which he explained as, " Thus shall 
it happen." The change in the character of the writing from 



CLINICAL FORMS 



175 



pretentious self-consciousness to stiff eccentricity is very 
characteristic. 

In the Further Course of the disease the specially 
striking disorders very gradually disappear to a certain 
extent. The patients become more accessible, quieter, 
complain less about the persecutions, possibly even begin to 
occupy themselves, though they may perhaps refuse regular 
work, because they are not paid, or are not obliged to work. 
Some patients become quite useful and eager workers. But 
along with that the hallucinations and delusions continue, with- 




Specimen of writing 6. Writing of the same patient seven months later. 



out being corrected in any way ; they only lose more and more 
their power over the actions of the patients. We may, 
therefore, contrast the terminal states which develop here as 
hallucinatory or paranoid weak-mindedness with the forms of 
mental decline hitherto characterized. The hallucinations 
persist but the patient "no longer pays so much attention to 
them," only speaks of them if he is asked explicitly about 
them, or even then says that he has already for some time 
heard nothing more, the last time was a few days ago. He 
also possibly allows that he has been ill, that it was a case of 
congestion, of nervousness, but yet he scarcely ever acquires 
a clear understanding of the character of the morbid 
phenomena. Meanwhile he learns to come to terms with 
them, does not let himself be influenced by them any more. 
A patient who still occasionally heard abusive voices while 
he worked outside as a painter, it is true, asked anyone he 
met, " What did you say?", but was at once reassured when 
he was told that no one was speaking, and he then knew that 



176 



DEMENTIA PRECOX 



it was again a case of " voices." Often the voices are heard 
at times more distinctly and still control the patient tempor- 
arily till quietness is again restored. This kind of patient 
occasionally speaks in terms of the most violent abuse, but is 

shortly afterwards completely 
accessible and up to a certain 
point intelligent. Such attacks 
occur especially at night, so 
that the patients then become 
very disturbing to their neigh- 
bours, while during the day 
they scarcely show any devia- 
tion from normal conduct. 

In about 20-25 per cent, of 
the cases temporary or per- 
manent hallucinations without 
further working up form the 
only striking residuum of the 
disease which has been under- 
gone. In the remaining cases 
there are still preserved a 
greater or less number of delu- 
sions, the significance of which, 
however, in the psychic life of 
the patients gradually disap- 
pears more and more. They 
do not speak much about them 
on their own initiative or they 
mention them without empha- 
sis like other indifferent sub- 
jects and do not become excited 
about them any more. Many 
patients still hand in from time to time documents with 
monotonous repetition of their former complaints and claims, 
possibly even still fall into excitement if one investigates 
their delusions, but accustom themselves to some or other 
regular employment. While the expression of their exalted 
ideas can still be recognized in their peculiar adornment, 
as in the patient pictured in Fig. 32, they yet adapt 
themselves in other matters without resistance to the daily 
routine of institution life. The "rex totius mundi " occupies 
himself with work in the garden, the " Lord God " with carry- 
ing wood, the " Bride of Chri.st " with sewing and darning. 
Of course this change always goes alongside of a blunting of 
the emotions. The patients have become more indifferent ; 
the circle of their interests, wishes, hopes, has narrowed itself 




Paranoid patient with ornaments. 



CLINICAL FORMS 177 

considerably ; their mental activity and their endeavour are 
extinguished. At the same time all sorts of traces of the 
former volitional disorders may still be preserved, singulari- 
ties in behaviour and especially in speech. 

The form here described seems to be just about as frequent 
as the former. Temporary disappearance of all morbid 
symptoms might occur once in a while quite exceptionally. 
Seizures were observed in 5 per cent, of the cases. Here also 
accordingly the whole history of the disease is unfavourable ; 
the course is slowly progressive. To the male sex belonged 
53 per cent, of my patients, a proportion that possibly is ex- 
plained by the fact that in Heidelberg numerous vagrants 
and prisoners from the neighbouring convict prisons were 
admitted, who with special frequency fall ill in the way 
indicated here. 

Causes. — About the cause of this remarkable process 
only hypotheses can be made. It might be that we have 
here to do with a form which develops specially slowly, 
and which for many years before the onset of the more 
striking morbid phenomena brings about changes in the 
psychic life, such as must lead to the path of the vagrant and 
of the criminal. For this view the fact would also speak, 
that apparently only 12 per cent, of our patients at the 
beginning of the malady had not yet passed their twenty-fifth 
year ; perhaps we would frequently have to place the begin- 
ning of the morbid change much earlier than usually happens 
according to the customary view of it. On the other hand it 
cannot be denied that clearly the influences of imprison- 
ment and of the workhouse are specially suited to produce 
paranoid conditions. We may therefore look at it somewhat 
in this way, that we have here to do with an unusually slow 
development of the morbid process, which makes it possible 
for the patient for a long time still to continue to live as an 
apparently healthy individual, while yet at the same time the 
increased difficulty in the struggle for existence, which results 
from the disorder, and the unfavourable influences of life 
favour the development of paranoid trains of thought. 

CONFUSIONAL SPEEgH DEMENTIA. 

A last very peculiar group of cases, the discussion of 
which has to be interpolated here, is formed by the patients 
with confusion of speech. These are cases of disease the 
development and course of which correspond in general to 
those of dementia praecox. On the other hand the issue is 
divergent. It consists in a terminal state, which is essentially 

M 



178 DKMKNTIA PR/ECOX 

characterized by an unusually striking disorder of expression 
in speech with relatively little impairment of the remaining 
psychic activities. If one will, one may therefore, relying on 
Hlcuier's nomenclature, speak of a " schizophasia." 

Commencement. — Sometimes a gradual failing with 
restlessness and silly actions, sometimes a moody condition 
with irritating hallucinations, ideas of persecution and 
serious attempts at suicide forms the beginning. Often the 
malady is developed in short attacks, between which there 
are remissions of considerable extent and lasting for years. 
Some patients sink to vagrants ; one became a crier at market 
stalls. But by degrees, now and then apparently within a 
fairly short time, the extremel)- remarkable morbid symptom 
is developed, which characterizes these patients above every- 
thing, confusion of speech. 

General Features. — Perception and memory usually 
show no considerable disorder, as far as can be judged from 
the utterances of the patients ; in any case the patients are 
clear about their place of abode, also about time relations, 
recognize quite correctly the people in their surroundings, 
even though they often give them wonderful names to which 
they usually adhere. Auditory hallucinations appear still to 
persist, but play no recognizable part in the psychic life of 
the patients and are not further worked up. Indications also 
of delusions appear, ideas of persecution, complaints about 
influences at night, " interpolations," and along with these 
there are exalted ideas. All these delusions are, however, 
extraordinarily vague, are only produced occasionally in often 
changing, often half-jocular, form, and acquire no influence 
over the rest of thought and activity. The patients are 
mentally active, accessible, show interest in their surroundings, 
often also follow the events of the day quite well. 

Mood is invariably exalted, self-conscious, at times 
irritable, usually pleasant ; the patients are lively, inclined to 
jokes and to little harmless tricks. Conduct and outward 
behaviour are reasonable, sometimes a little affected, submissive 
or whimsical ; the patients have the tendency to adopt all 
sorts of little peculiarities from which they are only with 
difficulty dissuaded. At the same time they are as a rule 
very useful, diligent and clever workers, who occupy 
themselves without assistance, but like to go their own way, 
ward off every interference in their doings, will not work with 
others, for the most part fulfil their obligations with great 
carefulness, but probably also once in a while do something 
quite nonsensical. In this way they usually fit in without 
difficultv in the life of the institution and make for themselves 



CLINICAL FORMS 179 

there a modest sphere of work, without giving utterance to 
more ambitious desires. 

Speech. — All the patients show a certain flow of talk 
which certainly only expresses .itself in conversation, here 
and there perhaps also in soliloquies. As .soon as they are 
addressed, they frequently answer with great vivacity and 
immediately take up the attitude of a lecturer. To simple 
questions put with emphasis they generally give a short and 
suitable answer. Or perhaps that throng of disconnected 
utterances, which was described before, begins immediately, 
or at most after the first still tolerably intelligible sentences. 
It is produced in flowing speech and with a certain satisfaction 
on the part of the patient. These utterances are mostly quite 
unintelligible and are richly interspersed with speech derail- 
ments and neologisms. Often the current can only be brought 
to a standstill by the interference of the questioner and 
can again be immediately put in motion by renewed question- 
ing. Sometimes it is possible from the behaviour of the 
patient and from detached, less nonsensical parts of the talk, 
to make at least very vague guesses what thoughts he wishes 
perhaps to express, stories of long ago, complaints, boasting, 
taunts, but all hidden in the most bewildering phrases which 
abruptly digress into the most remote domains of thought. 

An example of such utterances is given in the following 
letter : — 

"The sentimental vocation of tbe Welschneureuther citizens re- 
<juires above everything that after the subhme birthday festival of his 
Majesty the illustrious King William Charles, all his spiritual powers 
should be collected in order to do justice to their pastoral intercession in 
the Lord. So forty respected stormpatriots in view of the repeal of the 
statutes of the University of Erlangen have to-day taken it upon them to 
confirm as first retrospective negative in analogical-patriotic sense. To 
place at the most gracious disposition of his Majesty the Art. i of the 
Welschneureuther constitution, consisting in combustible available war- 
material, further most obediently to stop the most notorious dealings as 
intercourse with cattle, sheep and turkeys. Now in order that the 
sublime royal company cannot be subjected to any competition from the 
neighbouring states in transportable tempers all to be recommended to 
indulgence, we swear by the profit of enhanced merchandise only to 
serve each alone, only then to break off a consequence of the balance of 
the nineteenth century to be drawn periodically and mechanically, when 
we shall be able to be expectantly deceived in our opinions toward* our 
august ruler and regarded as a useful adviser of a healthy antiquarian 
museum and so on." 

On the whole the construction of the sentences here is to 
a certain degree preserved so that this drivel might perchance 
make the impression of internal connection, if it were read 
inattentively or by anyone who had imperfect understanding 



i8o DEMENTIA PR/ECOX 

of the language. On more exact inspection there is certainly 
no longer an>' question of that. 

Peculiarity of this Form. — It might be supposed that in 
the form of disease outlincd.it was only a case of drivelling 
dementia of a specially high degree ; there also incoherent, 
confused talk with neologisms and nonsensical phrases come 
to the front. But what distinguishes our patients here, is the 
sense and reasonableness in their behaviour and in their 
actions, which compels us to the assumption that this is a case 
not so much of a severe disorder of thought but much rather 
of an interruption of the connections between train of thought 
and expression in speech. In any case we have to do with 
an unusual restriction of the volitional disorder to a narrowly 
limited territory of volitional activity, that of expression in 
speech, in which it at the same time reaches a quite peculiar 
extent. Perhaps this limitation of the phenomena, which is 
certainly not quite strict, is conditioned by a special site of 
the morbid process similar to what we have seen in the 
atypical paralysis, still the possibility should probably also 
not be left out of account, that we have here before us a 
peculiar form of disease which is indeed related to dementia 
precox but is yet not essentially the same. 

The severity, with which the phenomenon of confusion of 
speech appears, is subjected to great fluctuation. Many 
patients are usually able to express themselves at first quite 
intelligibly, but fall into their nonsensical talk as soon as one 
speaks for a longer time with them or when they become 
excited. Further, periods are frequently noticed which recur 
with approximate periodicity, in which the patients are more 
ill-tempered or excited, and then become much more easily 
confused in speech ; it is exactly this peculiarit\- which com- 
pletely corresponds with the observations in the other terminal 
states of dementia prctcox. But lastly a state of confusion of 
speech may again disappear even after existing for many 
years, till only slight traces remain noticeable during excite- 
ment. That, for example, was the case of the patient from 
whom the letter given above originated ; he applied later in 
a quite correct way for a post. At the same time there is 
here certainly no question of real recovery. Lack of insight 
into their morbid state and lack of judgment, restlessness and 
aimlessness in work, a tendency to use high-sounding phrases, 
and superficiality of the emotions remain behind even ia 
favourable cases. 



CHAPTER VI. 
COURSE AND REMISSIONS. 

The general course of dementia praecox is very variable. 
On the one hand there are cases which very slowly and 
insidiously bring about a change in the personality, out- 
wardly not specially striking but nevertheless very profound. 
On the other hand the malady may without noticeable 
prodromata suddenly break out, and already within a few 
weeks or months give rise to a serious and incurable psychic 
decline. In the majority of cases with a distinctly marked 
commencement a certain terminal state with unmistakable 
symptoms of weak-mindedness is usually reached at latest 
in the course of about two to three years. One must always 
be prepared for acute exacerbations of the disease leading 
to a lasting aggravation of the whole condition. Not 
altogether infrequently the true significance of a change in 
the personality lasting for decades is first cleared up, by the 
unexpected appearance of more violent morbid phenomena, 
in the sense of dementia precox. 

The fact is of great significance that the course of the 
disease, as we have seen, is frequently interrupted by more 
or less complete remissions of the morbid phenomena ; the 
duration of these may amount to a few days or weeks, but 
also to years and even decades, and then give way to a 
fresh exacerbation with terminal dementia. Evensen saw a 
patient have a relapse after thirty-three years. Pfersdorff^ 
established improvement for the duration of two to ten years 
twenty-three times in one hundred and fifty cases (15 per 
cent.) ; I myself found real improvement in 26 per cent, of 
my cases, when that of the duration of a few months was 
also taken into account. It has been already mentioned 
that such improvement is to be expected most frequently 
in the forms which begin with excitement, and is almost 
entirely absent in paranoid forms of the disease as also in 
simple silly dementia; one is reminded here of similar 
experiences in paralysis, in which the expansive forms also 
exhibit frequent and considerable improvement while 
demented paralysis rarely does and, if it does, the improve- 

^ Pfersdorff, Zeitschr, f. klinische Medizin Iv. 1904. 



iS2 DEMENTIA PR/ECOX 

ment is only sliijht. Amonij women improvement seems ta 
be rather more frequent than among men. 

The Beginning of the improvement takes place as a rule 
very graduallw The excited patients become quiet; the 
stuporous more accessible and less constrained ; delusions 
and hallucinations become less vivid ; the need for occupa- 
tion and for the taking up again of former relationships 
becomes active. At the same time sleep, appetite, and 
bod}--\veight usuall)- improve considerably. But astonishing 
improvement may appear quite suddenly ; it then for the 
most part certainly does not last long. We find the patient, 
who up till then appeared to be quite confused in his aimless 
activit}- or his hopeless degradation, all at once quiet and 
reasonable in every way. He knows time and place and the 
people round about him, remembers all that has happened, 
even his own nonsensical actions, admits that he is ill, writes 
a connected and sensible letter to his relatives. It is true 
that a certain constraint of manner, a peculiarly exalted or 
embarrassed mood and a lack of a reall\' clear understanding 
of the morbid phenomena as a whole will always be found 
on more accurate examination. 

The Degree of improvement reached is very different in 
individual cases. Among those here worked up by myself 
there were 127 patients who ultimately became demented, 
in whom such a degree of improvement occurred, that a 
return to home life was possible ; in eight further cases which 
exhibited a periodic course, such improvement occurred even 
very frequently. In these latter cases, however, there existed 
in the intervals a distinct psychic weakness gradually 
increasing, which for the most part bore the stamp of simple 
emotional dulness and great poverty of thought, but was 
occasionally accompanied by slight, cheerful excitement, also 
perhaps by isolated hallucinations and delusions. That there 
was a state of even approximate health in the intervals was, 
however, quite out of the question. 

Duration. — Leaving these peculiar instances out of 
account, cases of improvement may be grouped according 
to their duration in the following way, if in the few patients 
whose state improved several times we consider only the 
longest period of such improvement: — 

No. of years i 2 3 4 5 6 7 8 9 10 12 13 14 15 16 29 

No. of cases with ) „ , 

periodsofimpt./ -' =^ -° '4 '4 4 6 3 2 5 3 1 2 2 i I 

In the great majority of cases therefore the periods of 
improvement do not last longer than three years. Among 



COURSE AND REMISSIONS 183 

those here noted it was stated sixteen times without reser- 
vation that the patients had been completely well. The 
duration amounted in 3 cases to one year, in 2 to two years, 
in 4 to three years, in 2 to five years, in 2 to six years, and 
I to four, I to seven, and i to twenty-nine years. In seven 
further cases the patients were described as "quiet," "orderly," 
" not attracting attention," and were at least in a position to 
earn their own living again without difficulty ; it was a case 
here of periods of improvement lasting two to three years, 
I of four years, and i of twelve years. There were also 
two cases in which the patients were described as well, but 
talkative and irritable ; in one of these cases, in which already 
two periods of improvement of several years' duration had 
preceded, the relapse leading to terminal dementia only 
occurred after fifteen years. In thirty cases the patients took 
up their work again as before, but appeared quiet and 
depressed, or timid and anxious, possibly also at times 
excited. One of these patients passed an examination well 
in the interval which lasted nearly three years. The duration 
of the improvement fluctuated for the most part between one 
and ten years ; it amounted in about half of the cases to 
over two years ; among these there were cases each of seven, 
eight, nine, ten, thirteen, and sixteen years. 

In twenty-six further cases there was to be noted an 
essential improvement of the condition but without the 
complete disappearance of all morbid phenomena ; here there 
were usually fairly short intervals which in half of the cases 
lasted less than two years. There were also ten cases in which 
after the disappearance of the more striking morbid symptoms 
there remained a distinct degree of psychic weakness, 
especially emotional dulness and lack of judgment ; in seven 
of these cases the improvement did not exceed three years. 
In a group of thirteen cases there remained marked 
restlessness and irritability with a tendency to passing states 
of excitement ; the duration of this state, till a fresh outbreak 
occurred, amounted nine times to over three years, five times 
to ten years and over. Perhaps there might be added here 
five cases, in which the patients during the period of 
improvement led a restless life and became vagrants ; in only 
one of these did the relapse follow in less than three years. 

In the cases which still remain, from which ten must be 
deducted, about which no sufficient information was forth- 
coming, the morbid phenomena were even in the intervals 
still more severe. Some of these patients were indeed quiet, 
but wholly unoccupied and stayed a great deal in bed ; others 
still gave utterance to delusions or suffered from hallucinations ; 



i84 DEMENTIA PR^ECOX 

strictly they ought not to be counted with those who had 
periods of essential improvement at all. Leaving them aside, 
we come to the conclusion, that i2-6 per cent, of the 
improvements bore the stamp of complete recovery, which, 
however, only seldom lasted longer than three to six years. 
Among all the cases ultimately leading to dementia the pro- 
portion of these periods of improvement resembling recovery 
only amounted to about 2'6 per cent., or in a somewhat wider 
acceptation to 4"i per cent. If we take all those cases 
together who were able to live in freedom without difficulty, 
and to earn their living, the proportion would rise to I3'3 per 
cent., and it would mount to about 17 per cent., if those 
patients were also counted, who, it is true, have experienced 
a distinct change of their personality, but still are to a certain 
extent able to live in freedom. The remainder, without 
regard to the cases which were not sufficiently elucidated, 
consists of those patients who indeed did not require further 
institutional care, but still on account of remaining disorders 
were not able to manage without special care. 

When the patients again fall ill, it is frequenth' in the 
same form as the first time, but sometimes it takes one of the 
other forms described above. Indeed this alternation of 
clinical forms, which is occasionally noticed, — depression, 
excitement, stupor, paranoid states, is, as in manic-depressive 
insanity, an important proof of their inner connection. The 
disorders may, according to the kind of relapse, appear again 
slowly, acutely or subacutely. Not at all infrequently there 
is seen, as in the first attack, after the initial improvement a 
gradual deterioration of the psychic state developing very 
slowly, till years afterwards more severe morbid phenomena 
appear. 



CHAPTER VII. 

ISSUE-TERMINAL STATES. 

The consideration of states of improvement is of the 
greatest importance for the question of general prognosis^ in 
dementia precox. " According to my former grouping into 
hebephrenic, catatonic and paranoid forms I had come to the 
conclusion that in about 8 per cent, of the first and in about 
13 per cent, of the second group, recovery appeared to take 
place, while paranoid forms probably never issue in complete 
recovery. These statements have been much disputed. The 
differences of opinion have certainly more to do with the 
limitation of what is to be regarded as recovery. Meyer 
found, when he followed their fate, 20 to 25 per cent, of his 
patients " with catatonic phenomena " so far restored after a 
few years that they could follow their calling and appear 
healthy to their neighbours. Racke, who after three to 
seven years made enquiries about his cases, found that of 171 
catatonics i5'8 per cent, might be regarded as "practically 
well," a number which does not materially diverge from my 
statement. Kahlbaum found recovery in one-third of the 
cases of catatonia. On the other hand Albrecht reports that 
among his cases of hebephrenia no real cure was observed ; in 
catatonia and in paranoid dementia on the contrary a few 
cases of recovery occurred. Stern saw recovery in dementia 
prgecox in 3'3 per cent, of his cases ; Mattauschek observed 
recovery in hebephrenia in 2'3 per cent., in his depressive 
paranoid form in in per cent., in the catatonic form in 55 per 
cent., in real catatonia in 4 per cent., and in dementia paranoides 
no recoveries at all. Zendig in his investigations arrived at the 
view that not a single genuine case of dementia praecox could 
be regarded as really completely recovered ; Zablocka also 
has taken up this view in his report on 515 cases. Schmidt 
who had over 455 histories at his disposal, states that in 57*9 
per cent, dementia had supervened, in I5'5 per cent, recovery 
with defect, and in i6'2 per cent, a cure ; the remainder had 
died. 

' Meyer, Miinchener medizin. Wochenschr. 1903, 1369 ; Racke, Archiv. f. 
Psychiatric xlvii. i ; Mattauschek, Jahrb, f. Psychiatric, xxx. 69 ; Schmidt, 
Zeitschr. f. d. gcs. Neurologic u. Psychiatric vi. 2, 125. 



i86 DEMENTIA PR/ECOX 

There are various grounds for the contradictory nature of 
these statements. In the first rank of course the delimita- 
tion of dementia pnecox comes into consideration. We 
shall see later that on this point, in spite of the ease with 
which the i^reat majority of the cases can be recognized, 
there is still great uncertainty. This is true in regard chiefly 
to the placing of the paranoid forms which are reckoned with 
dementia pnecox sometimes to a greater, sometimes to a 
smaller, extent, as also in regard to cases in advanced age 
in which likewise the arrangement in proper order in our 
morbid history may be variously handled. As in general the 
widening of the limits in both directions increases the number 
of cases which are prognostically unfavourable, there are here 
some causes for the variation of the figures got for recovery. 

Further difficulties arise from the varied delimitation 
towards the domain of amentia^ and of manic-depressive 
insanity. The cause of that lies in the imf)ortance, some- 
times greater, sometimes less, which is attributed to the 
appearance of the so-called "catatonic" morbid symptoms 
about the extent of which, moreover, opinions are likewise 
varied. In any case there still exists to-day to a not incon- 
siderable extent the possibility of cases of amentia and of 
manic-depressive insanity being wrongly attributed to 
dementia praicox and vice versa ; the prognosis of the 
disease will accordingly be more favourable or more un- 
favourable. 

In this uncertainty about the delimitation the statements 
of different observers can in the first place not be compared 
at all, not even the diagnoses of the same investigator at 
different periods of time separated by a number of years. 
But, even if this difficulty did not exist, we should further 
have first to agree about the idea oi cure. To begin with, the 
degree of recovery must be taken into account. Me\*er 
evidently docs not make the very strictest claims, and Racke 
speaks frankly of" practical " cures. But in dementia praicox 
in a considerable nuinber of cases all the more striking 
morbid phenomena may disappear, while less important 
changes of the psychic personality remain, which for the dis- 
charging of the duties of life have no importance, but are 
perceptible to the careful observer, who need not always be a 
relative. As the most manifold transitions exist between 
coinplete disappearance of all the disorders and the.se cases of 
" recovery with defect," the delimitation of recovery in the 
strictest sense is to a certain extent arbitrary, but just as much 
so also the determination, where "practical" cure passes into 
distinct psychic decline. On this account also the figures of 

' .Sec note on p. 275. 



ISSUE— TERMINAL STATES . 187 

different investigators will of necessity diverge from one 
another. Further also there is the possibility that in certain 
circumstances slight peculiarities which were already present 
before the patient fell ill, but which had remained unnoticed, 
or which are dependent on other conditions, may be wrongly 
regarded as consequences of dementia prxxox. 

But lastly, attention must be directed to improvement 
with later relapse, which has already been treated in detail. 
As improvement, which resembles recovery, may certainly 
persist far longer than a decade, we shall be able to pronounce 
a final judgment about the issue of an apparently cured case 
only after a very long time, and must even after ten or twenty 
years make up our minds to having few cases verified. In 
the majority of the researches, hitherto communicated, the 
time which has passed since the commencement of the 
improvement is much too short for the figures to give now a 
final decision on the prognosis of dementia pracox. Meyer, 
indeed, has taken up the standpoint that in relapses after a 
considerable time we have to do with fresh attacks of the 
disease and thus are quite justified in speaking of recoveries. 
It might, however, considering the many gradations in the 
length of the intervals, and in the severity of the slighter 
morbid symptoms which continue during their course, be 
quite impossible to determine the point when we no longer 
have to do with a flaring up of the morbid process which has 
been so long at a standstill, but with a really fresh attack of 
the disease. Later we shall, moreover, learn still other 
grounds which give evidence of an inner connection between 
attacks which are similar to each other though separated by 
considerable intervals of time. 

It is the difficulties here explained in detail which cause 
me for the moment to refrain from laying down new values 
for the prospects of cure in dementia prsecox. In any case 
for a very considerable number of apparently cured cases it will 
not be possible to bring forward now with any certainty the 
objection that it was a case of mistaken diagnosis or of 
temporary improvement which later was followed by relapse. 
On the other hand it will not be possible at the outset to 
deny the possibility of complete and lasting cure in dementia 
praecox. If a morbid process can remain quiescent for 
twenty-nine years, as in one of the cases observed by myself, 
it will probably be able also to attain to a complete cure. 
Still, the severe relapses after comparatively long and 
perfectly free intervals must suggest the thought that, as in 
paralysis, we have often to do only with a standstill or with 
extremely slow progress, but not with a real termination of 



i8S DEMENTIA PR/ECOX 

the morbid process. The experience, is, however, worthy of 
notice, that even amoiii^ the cases which terminate unfavour- 
ably, wliich form the foundation of my cHnical statements, 
many forms in a third of the cases, indeed in more than half, 
exhibit marked improvement, but which gives wa}' sooner or 
later to a relapse. As the frequency of essential improvement 
in any other disease could scarcely be much greater, it may 
reasonabh' be thought that the cases terminating unfavour- 
ably, which I selected, on the whole represent the general 
behaviour of dementia praico.x. Further researches into 
extensive series of cases observed carefully throughout 
decades must show how far the view, which is gaining in 
probability for myself, is right, that lasting and really 
complete cures of dementia pr^ecox, though they may perhaps 
occur, still in any case are rarities. 

An almost immeasurable series of intermediate steps leads 
from cure in the strictest sense to the most profound 
dementia. According to my former statements 17 per cent, 
of the hebephrenic and 27 per cent, of the catatonic form 
seemed to me to issue in a moderate degree of weak-minded- 
ness, while profound dementia occurred in the former in 75 
per cent, of the cases, in the latter in 59 per cent. Among 
other observers Zablocka found for hebephrenia in 58 per 
cent, of the cases slight, in 21 per cent, medium, in 21 per 
cent, high grade dementia ; the corresponding values for 
catatonia were 58 per cent., 15 per cent, and 27 per cent. 
Mattauschek reports for hebephrenia over 9"3 per cent, 
recoveries with defect, 209 per cent, dementia of the first 
grade, 67*4 per cent, dementia of severer degree. For his 
"depressive paranoid" cases the figures amount to in per 
cent., 24-1 per cent., and 53*7 per cent.; for his "catatonic 
forms" 138 per cent., 25 per cent., 55*5 per cent.; in 
catatonia 1 2 per cent., 20 per cent., and 64 per cent. Albrecht 
found recovery with defect in hebephrenics in 125 per cent, 
simple dementia in 27 per cent., high grade dementia of 
different kinds in 60 per cent, of the cases ; for catatonia the 
results were in 24 per cent, of the cases simple, in 50 
per cent, severe dementia. Stern established as issue in 
dementia pnecox in 367 per cent, slight, in 18*3 per cent, 
medium, and in 417 per cent, severe dementia. Evensen 
states that of his hebephrenics 5 per cent, remained 
independent, 25 per cent, at least still capable of work, and 70 
per cent, profoundly demented ; among the catatonics only 
50 per cent, became quite insane. I have invariably seen the 
jjaranoid cases issue in states of weak-mindedness, which in 
about half of the cases were of slighter degree, in the other 



ISSUE— TERMINAL STATES 189 

half of severer dej^ree. Simple weak-mindedness without 
other more striking morbid phenomena was the result in only 
7 per cent, of the cases. Mattauschek notes as terminal 
states in these forms in 2 11 per cent, of the cases slighter, 
in 78"9 per cent, severer dementia ; Zablocka in 65 per cent, 
slight, in 16 per cent, medium, in 29 per cent, profound 
dementia. A Ibrecht states that for the most part hallucinatory- 
weak-mindedness was the end of the disease, occasionally also 
simple dementia, recovery with defect, hallucinatory insanity, 
or even, as already mentioned, cure. 

As can be already recognized from this summary the 
statements of the individual investigators are at present not 
at all comparable. To the uncertainty of the diagnosis 
there have to be added the divergent grouping of the forms 
and the various judgments of the terminal states. It is 
indeed in high degree arbitrary how many grades of dementia 
may be distinguished, and how the individual cases may be 
distributed among them, especially as their condition may 
still often experience after a long time all kinds of transforma- 
tion. The grouping of the terminal states according to the 
morbid phenomena which principally appear in them, as has 
already been attempted in the foregoing presentation, perhaps 
offers a somewhat better prospect of scientific usefulness. 
Here also the placing of the individual case will doubtless be 
often uncertain ; still this classification at least brings the 
terminal states into closer relations to the preceding clinical 
pictures. 

Simple Weak-mindedness. 

The first form, which from this point of view we may 
delimit, is simple weak-mindedness without other striking 
morbid phenomena. The weakness lies, corresponding to 
the principal points of attack of the disease, specially in the 
domain of emotion and volition; to a less degree judgment 
and still less memory are involved. After the disappearance 
of the more marked morbid symptoms the patients seem to 
be clear about time, place, and person, also about their position, 
p.nd give reasonable and connected information. Hallucina- 
tions disappear in the main, especially the voices ; only now 
and then perhaps " hissing sounds " occur still once in a way, 
or the patient sometimes hears his name called, but with an 
effort can get away from it, does not pay attention to it any 
longer. Recollection of the time of the disease is usually 
clouded. Still the patient knows that he has heard " inward 
voices," thought he was in heaven, was anxious. He also 
states that now his head is not being electrified any longer,. 



I90 DEMENTIA PR.-ECOX 

that the voices have stopped, and he denies more or less 
definitely tiie former delusions; he "won't be a guardian- 
an;^el any lonijer," " can't work any miracles." 

Understanding of the significance of the morbid pheno- 
mena is at the same time often very defective. The patient 
perhaps admits that he has been confused, has been suffering 
from his nerves, but considers the illness that he has passed 
through quite harmless, and himself quite well ; and he does 
not feel any need of enquiring further about the nature 
of his disease and its course. Many patients connect their 
morbid conduct with chance external causes, wrong treat- 
ment by relatives, life in the institution ; " It was only 
dissimulation," said a patient. Sometimes perhaps even a 
few delusions which have arisen during the course of the 
disease are retained uncorrected, though the patients do not 
speak of them any longer, and do not let themselves be 
influenced by them any longer. 

Alsx:) in other directions a distinct weakness of judgment 
appears as a rule. The patients have become incapable of 
taking a general view of more complicated relations, of 
distinguishing the essential from side issues, of foreseeing 
the consequences of their own or other people's actions. 
Their circle of ideas appears to be narrowed. .Although 
occasionally still a considerable residuum of knowledge 
formerly acquired ma)- come to the surface, \"et the patients 
have lost the capability of making use of it, and of working 
with it, a circumstance which naturally brings about its loss 
by degrees. The patients therefore lo.se a great part of 
their knowledge ; they become impoverished in thought, 
monotonous in their mental activities. As at the same time 
their attention is blunted, they have but little inclination or 
ability to learn anything new, to pursue aims, to carry out a 
more extended plan. " She has no memory at all when she 
works," the father of a patient wrote; '"He hasn't got 
enough sense," another rejjorted about his son. In slighter 
cases, however, acquired proficiency remains fairl\' well 
jjreserved. Many patients play cards or chess well ; others 
can do arithmetic, draw and write with great perseverance, 
but are perhaps quite incapable of appreciating corrections, 
mistakes in spelling, or interpolations properly, or of planning 
anything themselves. 

Mood may be of very various colouring. The lack of 
deep emotion, however, is the characteristic feature. The 
patients regard with indifference the events of life, live a day 
at a time without endeav^our, without wishes, without hopes 
or fears. A patient replied to the question, whether he did 



ISSUE— TERMINAL STATES 191 

not wish to return home, " It is the same, whether I stand 
about here or there." The relation to their relatives becomes 
cool, sometimes directly hostile; former interests are weakened 
or extinguished ; work is accomplished mechanically with- 
out inward participation. At the same time the patients 
frequently exhibit depressed, suspicious behaviour, not very 
accessible, at times irritable and sensitive, occasionally accom- 
panied by ideas of jealousy. They must " be treated with 
love and consideration," as one of the patients put it. Other 
patients are cheerful, untroubled, confiding, erotic; often there 
is a tendency to laughing and smirking without recognizable 
cause. 

The Outward Conduct of the patients is in general 
reasonable ; only they often exhibit a stiff constrained 
demeanour or a somewhat odd behaviour, singular clothing, 
neglect of their person, small peculiarities in speech, gait and 
movement. One of my physicians noticed a young mason 
who in placing the stones turned them in a curious way ; it 
was a patient of our hospital who was " cured with defect." 
In a few patients there remain indications of automatic 
obedience. Many patients are quiet, taciturn, constrained*, shy, 
withdraw themselves, avoid people ; they appear obstinate, 
unresponsive, intractable, do not go any more to church or 
public-house, always sit on the same chair, stare in front of 
them. Others on the contrary are childishly intimate, access- 
ible, docile, but not independent ; others again display signs 
of slight excitement, grumble, try to get away, are prolix, 
somewhat incoherent in their talk, over-polite, abusive at 
times, occasionally perpetrate nonsensical actions, destroy 
anything, throw their watch into the water-closet, compose 
confused documents, fall into drinking habits. One of my 
female patients, who up till then had been a respectable girl, 
gave birth in a remission of five years' duration after severe 
catatonic excitement to three illegitimate children, the last 
of which she smothered by carelessness ; during detention 
there then occurred a fresh, very violent attack of catatonic 
excitement which led to simple dementia ; seven }'ears later 
in the institution she again passed through a severe attack 
of excitement which passed off rapidly. 

Capacity for work is as a rule diminished. Many 
patients, it is true, are diligent, but cannot be set to every 
kind of work : " The will to work is perfectly good, but 
accomplishment is deficient," wrote the relatives of a patient. 
Sometimes they make very peculiar and useless things. 
Their previous employment has very frequently become too 
difficult for them ; they look out for easier work. The former 



192 DEMENTIA PRECOX 

fine mechanician becomes a simple locksmith, the student a 
copyist, the artisan a day-labourer. There is no question 
of deliberate endeavour to make good use of or to improve 
their own condition. They live a day at a time, squander 
what they earn, take no thought for the future. Some 
patients absolutely refuse to work, loiter about aimlessly, 
take walks, stay in bed for days. Not infrequently a very 
great need for sleep is observed, also considerable appetite, 
while other patients must always be pressed to eat. " Half 
nourishment is enough," said a patient. Complaints about 
headache are frequent. 

The degree of development reached by the morbid pheno- 
mena which have been described of course varies to a very 
great extent. In numerous cases the changes are so trifling 
that they can only be recognized by those in close contact 
with the patient and only by good observers. The patient 
has merely become a little quieter and more self-willed, more 
capricious ; he appears more absent-minded, more indifferent, 
gives up the execution of more ambitious plans, works more 
mechanically, but is able to fulfil the usual claims of the day 
quite well. If one will, one may here speak of a " practical " 
recovery, although a complete and radical cure of the morbid 
process has not taken place, as is then proved by occasional 
fairly severe relapses. But even the more marked forms of 
this simple weak-mindedness usually exhibit no very striking 
psychic morbid picture and are often enough regarded from 
the point of view of moral offence, especially when they have 
developed slowly. This is seen in those patients who sink in 
an apparently incomprehensible manner from the position in 
which birth and breeding had placed them, indeed in certain 
circumstances to be habitual criminals, vagrants, prostitutes, 
without the morbid nature of the change which is taking 
place in them being recognized. This accounts for the 
frequency with which more marked morbid states are 
developed in them when after a restless life full of excite- 
ment, privation and excesses, loss of freedom brings on them 
still further severe injury. 

Hallucinatory Weak-mindedness. 

Next to simple weak-mindedness there come perhaps those 
forms of psychic decline, in which as residuum of the disease 
through which they have passed, besides a more or less 
severe loss in mental capacity, some hallucinations are still 
left, which are regarded by the patient himself as morbid 
phenomena or at least are not further elaborated. 



ISSUE— TERMINAL STATES 193 

Auditory Hallucinations play the principal part Some- 
times only very occasionally, sometimes more frequently, but 
still always with great fluctuation, they torment the patient ; 
sometimes they occur specially at night. What the voices 
say frequently consists of fragmentary cries, which are often 
repeated in the same phrases and are sometimes quite in- 
different, sometimes mocking, even perhaps nonsensical or 
incomprehensible, occasionally in a foreign language. Other 
patients hear question and answer or whole conversations ; at 
the same time noises, murmurings, knockings, are perceived. 

The hallucinations of hearing of the patient have mostly a 
certain connection with his train of thought, though some 
utterances appear wholly bewildering and unconnected. " I 
was never wholly free from the idea, that a strange person 
was interfering in my mental sphere," wrote a patient who at 
the time had been in a responsible position in life for more 
than twenty years without any morbid symptom ; "Thoughts 
flash up at times without my seeking them at all." Another 
patient describes his disorders very vividly who likewise, after 
passing through an acute attack fifteen years ago, has been 
continuously diligent in his calling though with much inward 
difficulty : 

"The utterances accompany my own thinking, but in such a way 
that I always can separate them from it. Sometimes they are mixed 
with the formation of thought itself ; that is then specially tormenting, 
and the more tormenting the shorter the moment is between my thoughts 
and the corresponding utterance of the voices. As regards what they 
say the voices bring professed news about everything possible and 
impossible, the Emperor, the Crown Prince, their consorts, my superiors 
and colleagues and their families, relations and friends and also about 
my chance surroundings. Sometimes I have the impression, as if 
certain persons, known and unknown, could become aware of my 
thoughts, were inwardly encountering me in a friendly or hostile manner. 
As I fear that from such thoughts mania of persecution might arise, 
I oppose them with all the power of logic." 

Here unmistakably it is a case of the same disorders 
which we have met with so often in the description of the 
clinical morbid pictures. It is only the attitude of the patient 
towards the hallucinations that has changed, a sign that we 
have only to do with a limited residuum of the former malady 
and no longer with a morbid state of the whole personality. 

An excellent view of these processes is given by the 
following notes written by the same patient of what he 
heard at intervals ; among them the questions which were 
inwardly directed to the voices by the patient are given 
in parentheses :— 

(Why are you speaking in me ? ) " You may eat blood. A. must 
laugh at you. Because we are poor blockheads. Asylum. We'll bring 

N 



194 DEMENTIA PRECOX 

you later to an asylum. O my dear genius I Because we are hypochon- 
driacs. 1 am your poor marmot. We are the mistresses of the German 
whipping-club. We inhale you." (Why do you torment me?) "Have 
you a fate I We think the best of you. Taraxacum ! Taraxacum ! 
We thrash Dr S.'s bones bloody for he has become surety for you. 
Because we are frightfully fond of you. What am I to do ? We weep 
laughing tears. We are differently developed. O you my darling little 
Jesus. Because we ourselves are tormented. Because we morally act 
perversely. We have christian catholic morality. Every human being 
must laugh at you. You are mentally ill. Yes, it is so. Because we 
have to fear your brain grease. O wild sheikh Almagro ! Whom one 
loves, one torments. We have no implements of handicraft. You are in 
many things an absolute child, an absolute fool 1 We torment you as 
moral rapscallions!" (What is your real object.'') "We wish to kill 
you. You have offended divine providence. Our object is morally 
irrelevant. M. must laugh at you. Our object is your cleansing. But 
Absalom I We love and hate you. Our object is terrible establishment 
of women's regiment. We are silly." (Are you human beings or 
spirits?) "We are human beings, old topswine ! O that needs an 
insane patience I I will show you my last aims. We weep about you. 
You have been very prudent. We are climbing up Ararat. Now then, 
little spirits ! Little folk, brownies I You are fundamentally insanely 
deep I " (Shall I get well again ?) " Not according to the plan of the 
women's regiment. Now then, no ! For you have the delusion of 
persecution. We only want to try you. You are not mentally ill. 
Have you then no idea of your significance ? We are moral female 
anarchists. Yes certainly, in God's counsel. Have you not delirium ? 
For God's sake, you make a note of everything. Haven't you let loose 

the werewolves at us ? Between mountain and deep, deep valley " 

(.A^re you near 1) " No, far away. What shall we do contrary to your 
interests ? No, in the middle of your head ! '" 

These notes, which reproduce about the half of what was 
heard in an hour, let it be seen that the voices answer the 
questions inwardly addressed to them, though not always 
immediately. In between are interpolated all possible dis- 
connected remarks and exclamations. In many of these 
utterances the personal attitude taken up by the voices 
towards the patient appears distinctly, as we observed it at 
the height of the disease in connection with ideas of persecu- 
tion and exaltation. The voices mock, deride, threaten the 
patient and his friends, reproach him, bewail, praise and 
admire him ; they indicate that they have power over him 
and dwell as spirits in him. Along with this a marked 
morbid feeling makes itself noticeable in the phrases about 
asylum, mental disease, delirium, mania of persecution. 

Visual Hallucinations usually play a smaller part. 
Many patients .see, especially in sleepless nights, all possible 
figures, effects of light, or objects appear distorted. Other 
patients have pictures of individuals forced on them, some- 
times with, .sometimes without, connection with their other 
trains of thought. Occasionally also all .sorts of bodily 



ISSUE— TERMINAL STATES 195 

dySc'Esthesiae are reported, especially oppression in their head 
and sensations of giddiness. 

Mood is mostly depressed. The patients feel themselves 
tormented, inwardly constrained, hindered in their capacity 
for work ; they incline often to painful self-observation, make 
complaints about sleeplessness, digestive disorders, states of 
anxiety. Many patients learn gradually to come to terms 
with their troubles in some measure, and by a prudent and 
regular life and avoidance of greater exertions, excitement 
and excesses, to preserve their capacity for work. Even in 
them, however, a quiet, shy, reserved behaviour usually 
accompanies the loss of self-confidence and independent 
energy, which results from the continuance of the morbid 
residua. " My success in controlling my disease I owe 
principally to my own self-restraint and to taking measures 
for my state as soon as it becomes intolerable," wrote a 
patient. 

In other cases the damage to the psychic personality 
goes much deeper, even to the production of marked weak- 
mindedness. The patients do not correct the hallucinations, 
but they do not speak about them any longer ; they do not 
listen to the voices any longer, do not get excited about 
them ; " that's useless, there's no aim in it." Many patients 
are probably still irritated temporarily by the " voices of 
persecution," abuse them, especially at night, stop their ears, 
speak now and then low to themselves, but between times do 
not wish to know anything more of them, go on with their 
work without disturbance. At the same time there is invari- 
ably found a greater or less narrowing of interests, a weaken- 
ing of emotional relations, a loss of volitional activity, often 
also a repellent, reserved behaviour. 

Paranoid Weak-mindedness. 

Obviously those terminal forms of dementia prsecox, in 
which uncorrected delusions continue to exist, injure the 
psychic life essentially more profoundly than the " hallucina- 
tory weak-mindedness" above described. We met them as the 
invariable terminal states of "dementia paranoides mitis," 
but they come under observation here and there as the issu e 
of other forms conjoined with delusions, though perhaps in 
somewhat divergent form. Above everything it is ideas of 
persecution which are permanently adhered to after the dis- 
appearance of the more acute morbid phenomena, mostly in 
a very monotonous way and without substantial elaboration, 
but in gradually ever more nonsensical and incoherent 



196 DEMENTIA PRECOX 

expressions. At the same time the most varied hallucina- 
tions also usually play an important part. It is the old 
story ; the persecutors are still always there. The patient is 
abused, mocked, electrified, stupefied, blinded, plagued by 
witches ; by day and by night experiments in physics are 
carried out, specious political business, rascally tricks. His 
children are being murdered, his money withheld from him, 
his throat slit up. Obscene things are said, his nature drawn 
off, his semen poured out. The patients " must answer the 
voices," must do what they command. On the other hand 
the\- hear voices from God saying that they are Christ, that 
they are queens by birth, that they are to get millions. In 
course of time the delusions fade somewhat, it is rather better, 
the patients say. " Electrification is rather less." At the 
same time a certain morbid feeling may appear. The 
patients say that they had often suffered from disorders, 
had confused thoughts, cannot work properly, are a little 
" mentally affected." 

About their surroundings and their position in general, 
the patients are usually for the most part clear, so far as 
delusional occurrences do not play a part. Their train of 
thought remains fairly connected and reasonable, but easily 
becomes incoherent and confused, as soon as their delusions 
are suggested and they fall into excitement. 

Mood is morose, often very irritable, more rarely dull or 
exalted. At times the patients become threatening, abusive, 
violent ; they shut themselves up, indulge in superior irony. 
Nevertheless they are often able to occupy themselves with 
success and aptitude, though at the same time they like to go 
their own way. Slight indications also are often found of the 
volitional disorders characteristic of dementia pra.'cox. The 
taciturn, thoroughly inaccessible, behaviour of many patients 
might not be caused only by their delusions but at least partly 
by negativistic action ; in others we observe mannerisms, 
smacking with the lips, spitting, repetition of questions 
addressed to them, queer ways of expressing them.selves, 
singular clothing. 

Dementia— Drivelling, Dull, Silly, Manneristic, 
Negativistic. 

If we try to carry out the classification of the terminal 
states according to the special characteristic which is im- 
pressed on them by the permanence of definite morbid 
phenomena from the earlier periods of the disease, we shall 
be able to distinguish a series of forms in which sometimes 



ISSUE— TERMINAL STATES 197 

mental weakness, sometimes emotional dulness, sometimes 
one of the peculiar volitional disorders more specially 
dominates the condition. Of course it is never a question 
here of sharp limitations, as little as in the various courses of 
the disease previously described. Much rather we shall find 
again everywhere the fundamental features of dementia 
pr.-Ecox, only that here the one peculiarity, there the other, 
is more strongly represented. Clinical relations to the 
former morbid pictures exist in so far that in the terminal 
state only such symptoms are preserved as had already been 
developed, but they may later even completely disappear. 
While we therefore have recognized in simple weak-minded- 
ness an issue which signifies a disappearance of all the more 
striking disorders and therefore in general a milder course of 
the malady, there remain permanently in the following forms of 
the psychic decline distinct morbid phenomena in particular 
domains of the inner life. At the same time a considerable 
disappearance of the morbid disorders may take place in 
some or most of the other domains, so that we find besides 
the more striking characteristics of the terminal state, some- 
times only very slight, but sometimes also very deeply- 
spreading changes in the rest of the psychic personality. 

Drivelling Dementia. — If in the "paranoid" terminal 
states we had to do essentially with a continuance of the 
delusional morbid processes, the characteristic of drivelling 
dementia is the general decay of mental efficiency. Here also 
are still found, as a rule, hallucinations and delusions, the 
senselessness of which distinctly proves the mental weakness. 
The patients hear the voices of devils, spirits calling, are 
tormented by senseless telephoning; thoughts are blown into 
them ; they speak with the voices. They are influenced, 
bled every evening, have their genitals pulled at, are pressed 
together, sucked out through a needle, castrated, punctured ; 
they are beaten on their heads at night with an iron hammer ; 
they smell blood and corpses. The doctors procure abortion ; 
the connection between the uterus and the rectum is gone, 
their flesh is adulterated. Little children are sitting in their 
neck ; the female sexes have suffered very great want ; there 
is quackery going on, subterranean vapour business, silly 
speculation. The patient is the son of primal force, has a 
divine calling, is the Lord, suffers for the whole of mankind, 
is singled out for distinction by the Grand Duke, demands 
special food, is going to marry. All these delusions are 
given utterance to without connection and without emphasis, 
in often changing, always more extraordinary form. Not 
infrequently a certain morbid feeling exists at the same 



198 DEMENTIA PRECOX 

time. " We're not quite well yet," said a patient ; another 
said, " I used to have the delusion that I was the King of 
Bavaria, or I was the Lord God ; that's just nonsense," while 
a third declared, "The abuse was in the disease"; again 
others say that their sense has been taken from them. Or 
thev allege, if they are asked about hallucinations and 
delusions, that they do not hear so much now, do not pay 
attention to it, do not take themselves up with these things 
an\' more, have forgotten them. 

The really characteristic disorder, however, in this form is 
iticohercucc of the train of t/iought. The most loquacious 
patients ever afresh bewilder their hearers by the confusion 
and singularity of their utterances and by the senselessness 
of their associations of ideas. " I am bird black," declared a 
patient, another, " I am no country," a third, " I am your 
deceased father," a fourth, " I believe that my father is now 
born," a fifth, " That he was tuned at the turn of the year." 
The following are examples of similar utterances already 
reaching into the domain of confusion of thought and quite 
similar to conversations in dreams : " I speak with the voices 
for my welfare elements," "If one may serve after the right, 
the left must become," " In this custom there are very difficult 
tasks," " I still hear voices, where does right and the damage 
sits above." We may, therefore, well assume that it is a case 
here not only of disorders of the train of thought, but also of 
disorders of expression in speech. Further, the circumstance, 
that silly clang-associations and neologisms frequently come 
under observation is in favour of this view ; many patients 
speak in a self-made language. The loquacity and the 
richness of vocabulary might point to a relationship with 
sensory aphasia. Incoherence is usually most in evidence 
when the patients converse for some time and fall into 
excitement, while they often answer simple questions quite 
correctly. 

The patients are often not clear about their position and 
their surroundings. They mistake people, and call them by 
quite arbitrary names. They are in a " house for a manure 
king " ; the)' are " there because of an offence to the catholic 
church," have "a religious affair," " must do business." 

Mood is changeable, often self-conscious, silly, cheerful 
but irritable ; it easily comes to violent excitement suddenly 
exploding. The deeper emotional relations are blunted ; the 
patients do not trouble themselves about their surroundings, 
remain indifferent when their relatives visit them, show 
neither interest nor perseverance in work. 

Volition. — Here also we invariably meet with manifold 



ISSUE— TERMINAL STATES 199 

volitional disorders. Some patients exhibit automatic obedi- 
ence, catalepsy, echophenomena, others are repellent, 
unmanageable, at times refuse food, become mute, hide 
themselves away in bed, retire if any one approaches them, 
force their way out senselessly, speak past the subject, do not 
shake hands ; " I can have no more intercourse with you," 
declared a patient ; " It's no use giving a paw," said another. 
But most frequent are mannerisms of all sorts, making faces, 
singular attitudes, kneeling, affected movements, rhythmical 
swaying, running up and down, shaking their heads, scratching, 
monotonous gestures, spitting, licking, smacking with their 
lips, wiping, screeching, shrill singing, mincing speech, lisping, 
speaking in falsetto, whispering, impulsive laughing, obscene 
abuse, remarkable hairdressing and garments, peculiar spelling. 
Many patients are dirty; many visit the water-closet 
innumerable times. 

Dull Dementia. — In a further group of terminal states 
the loss of emotional activity is more striking than anything 
else, so that we may here speak of a " dull dementia." 
Hallucinations and delusions only play a small part here. 
Many patients, it is true, state when asked, that they still 
hear the same as before, " filthy things," " the wicked enemy," 
but they do not speak about them any more of their own 
accord ; others " have forgotten hearing voices " or only hear 
quite indifferent things. Now and then the patients state 
that they are being influenced, poisoned, that their veins, 
their skulls are burst, their parents beheaded, that at night 
there is examination and impropriety, that human flesh is 
given to them, that they have intercourse with the Lord God, 
but such ideas are not further elaborated and they acquire 
no determining influence on the conduct of the patient. The 
surroundings are as a rule correctly perceived, though the 
patients may have little inclination to account to themselves 
for people or events in any way. Much rather they live their 
lives dully and without taking any interest, do not trouble 
themselves about their relatives, do not reflect about their 
position, do not give utterance either to wishes, or hopes 
or fears. 

Mood. — At the same time the slightly marked colouring 
of the background of mood is sometimes more gloomy, 
anxious, or lachrymose, sometimes more that of a vacant 
cheerfulness with frequent smirking or laughing. But often 
without recognizable occasion dull indifference is from time 
to time interrupted by violent excitement with confused 
abuse and a tendency to sudden destructiveness and even 
to serious deeds of violence, of the causes of which the patients 



2C» DEMENTIA PR^ECOX 

are not able to give any account ; he had too much blood, 
said one patient. These states may recur with a certain 
regularity. 

The Volitional Expression of the patients shows very 
severe disorders. They are for the most part quiet, taciturn, 
or quite mute, sit about in corners, remain standing wherever 
they are pushed, do not get out of bed. They do not try 
to get away ; they are prepared to stay where they are, till 
they are fetched away ; they do not plan to begin anything. 
On the other hand they are often able to do simple work, 
such as sawing wood, carting, shovelling with great per- 
severance, if they are put to it. Rhythmical ?Lci\ons especially 
are continued by them, till they come up against some 
hindrance, at which they then stop, till they are again set 
going. Attitude and behaviour are sometimes slack and 
negligent, sometimes stiff and constrained; movements are 
clumsy, uncouth, awkward. Marked automatic obedience is 
very frequent; Weygandt ^ was still able to demonstrate it 
in a case after the disease had lasted for fifty-four years. 
Further also we often meet with negativistic features. The 
patients do not look up when they are spoken to, do not 
answer, stare straight in front of them, do not shake hands, 
avoid people, every now and then stop working for a few 
days and refuse food, or they hide away under the bedclothes. 
Now and then speaking past the subject is observed, or quite 
unconnected answers are given ; a patient replied to the 
usual greeting, " Respect for religion ought not to be." 
Lastly, impulsive and manneristic actions are also not lack- 
ing, especially in the ever-returning states of excitement. 
The patients make faces, assume singular positions, make 
monotonous movements for hours at a time, play with their 
fingers, strike their own faces, shake hands with the little 
finger or with the left hand, slide about on the floor, run 
up and down, rub and wipe things, spit, suddenly cry out, 
mutter unintelligibly to themselves. They usually quiet 
down again very quickly and then sink back into the old 
dulness. 

Silly Dementia. — Impulsiveness and weak susceptibility to 
influence are the striking characteristics of those terminal 
states which we class together as "silly dementia" ; they 
form the invariable issue of that clinical type which we 
formerly delimited under the same name. Hallucinations 
and delusions are frequently entirely lacking here. On the 
other hand a considerable degree of weakness of judgment 

1 Weygandt, Centralbl. f. Nervenheilk. u. Psychiatric, 1904, 615. 



ISSUE— TERMINAL STATES 201 

invariably exists. The patients have no understanding of 
the kind or of the extent of their disorder or of their actual 
position, consider themselves well and able for work, although 
they perhaps still sometimes suffer from "blocking of thought." 
They wish to take up their occupation again, do not under- 
stand why they are prevented from doing so. About their 
surroundings and what occurs in their neighbourhood they 
are quite clear ; they certainly form quite erroneous opinions 
about details, regard their fellow-patients as well, treat their 
dreams as real occurrences. They are able to occupy them- 
selves, write letters and petitions usually of a very monotonous 
kind, sometimes with verbal identity. Their acquired know- 
ledge may be fairly well preserved ; still in time a certain 
mental impoverishment always appears, as the patients are 
not able to use what they have learned. At every difficulty, 
the solution of which requires independent thought, they 
habitually fail in a surprising manner. 

Mood is invariably confident and cheerful, more rarely 
and only temporarily depressed and lachrymose. But for 
the most part the patients are easily excited and fall suddenly 
into lively agitation or into quickly passing outbursts of 
rage, sometimes with periodic return. The lack of fine 
feeling is usually very striking ; it makes the patient wholly 
forgetful of the regard due to his personal dignity as well 
as to the feelings of the people round him. In the same 
way foresight in relation to the events of life and to the 
results of his actions and the ability to carry out any plan 
consistently are also lacking. His whole demeanour bears 
the stamp of childish thoughtlessness and stupidity. He 
chats without ceremony about his most delicate affairs, uses 
disrespectful expressions about his parents and superiors, 
exposes himself in the most incredible way. He follows 
sudden fancies without hesitation, is sometimes immediately 
susceptible to influence, sometimes incomprehensibly obstinate. 
He fills his time with aimless occupations. "The will is 
present but I don't bring it together," said a patient. Often 
a certain restlessness exists which drives the patient. to all 
sorts of foolish actions. He decorates himself in an extra- 
ordinary way, grunts, frisks about, howls, plays with dolls, 
smears everything, makes faces, chats and writes a great 
deal, composes insipid rhymes, speaks in affected phrases, 
makes up singular words. 

Manneristic Dementia. — In a further form of terminal 
state which we shall term manneristic dementia, singular 
changes in volitional actions are in the foreground of the 
clinical picture. For the most part hallucinations and 



202 DEMENTIA PR/ECOX 

delusions are still present here also. "There are still always 
enouj^h voices," said a patient. They torment him the whole 
day, call out "Filthy fellow"; it may come from the tele- 
phone, or it is inward speaking, voice annoyance. There are 
influences at night ; there is foul air in his ear. His nature 
is not pure ; torture is being carried on ; it is known how 
that hajipens, a fatal blow, poisoning of witnesses. Figures 
descend from heaven ; the patient is being murdered by 
witches, is given the flesh of his burnt relatives to eat. He 
is burned inwardly, blown to pieces, has five diseases, must 
die; his heart has been stolen. Other patients are John the 
Cherusker, Frederick Barbarossa, the German Emperor, wish 
to be Prince of the world, a statesman. Many patients are 
quite confused, mistake people, have " no more sense or idea 
of nothing." Now and then a certain morbid feeling is 
present. The patients state that they are scattered in their 
minds, they cannot remember anything, cannot think in 
their heads, do not recall things as they used to do. Former 
morbid phenomena are sometimes denied ; the patients will 
have nothing more to do with the voices, " don't speak any 
foreign language now." 

Mood is often exalted, self-conscious, but frequently also 
peevish and irritable, more rarely dull or lachrymose. The 
patients smirk and laugh, but at times fall into violent 
excitement, break out into wanton and obscene abuse, 
suddenly become violent and destructive. 

Their whole conduct is dominated by singular impulses, 
which lead to their carrying out senseless actions, to diminu- 
tion, derailments, and in the end to the suppression of their 
volitional utterances ; along with that very commonly 
stereotypies develop. The bearing of the patients is stiff 
and constrained ; their movements are affected, theatrical, 
often jerky and inelegant. They assume uncomfortable 
positions, lie on their stomach, on their face, twist themselves 
together, hold their head, press their hand before their mouth, 
close their eyes, put out their lips like a snout. They run 
round* in a circle for hours, beat themselves, impulsively 
touch the handle of the window, dance about, suddenly 
run through the room, pull their ears, pull at their fellow- 
patients, devour urine and faeces, bite their nails off, pluck 
their finger-tips to pieces, sway rhythmically to and fro, 
spit about them, masturbate, smudge things, make faces. 
They adorn themselves in an extraordinary way, make 
singular gestures, affected bows, walk and eat in a manneristic 
way, shake hands with their thumb or two fingers, smack 
their lips, and click their tongue. Pictures of these con- 



ISSUE— TERMINAL STATES 



203 




Fig- 33- Patient hopping. 



ditions are given in Figs. 33 and 34, which represent a 
patient on one leg hopping about and another sitting in a 
distorted attitude. 

Speech. — In the speech 
also of the patients manner- 
ism makes itself felt in most 
manifold ways. The patients 
declaim, preach, speak in a 
washed-out way, mawkishly, 
with closed teeth, lisping, in 
a foreign or self- invented 
speech, with child-like pro- 
nunciation and accent; they 
give unconnected answers, in- 
dulge in silly puns and clang- 
associations, odd expressions 
and neologisms. One patient 
said he was a wicked world- 
begetter, another said, " Down 
there is Hell ; she is called 
Miiller"; another spoke of 
" Witch - begging- rascal -fur- 
nace." In many patients 
automatic obedience can be demonstrated ; but negativistic 
features are much more frequent. Their capability for work 

is mostly slight, and is usually 
limited to mechanical activ- 
ity, copying, knitting, sawing 
wood, and that kind of thing, 
even in the most favourable 
cases. 

Negativistic Dementia. — 
As the last form of decline 
induced by dementia prae- 
cox we take into considera- 
tion negativistic dementia, 
in which the phenomena of 
impulsive resistance appear in 
a specially marked way. It 
is nearly related to the last 
form, since there just as here 
varied volitional disorders are 
usually combined with each 
other. About hallucinations 
or delusions little is heard 
from the patients, probably 




Fig 34. Patient in distorted attitude. 



204 



DEMENTIA PRyECOX 



for this reason that they are not at all inclined to make 
statements. Still many patients abuse the voices which " go 
against the man," close their ears, complain about " the 
extortion of the extortioner- Bismarck." Others demand 




Fig. 35. Patient continually holding her head. 

" their money " ; they have no one for a friend, are first 
doctor, the Christ-child in the manger. The substance of 
their conversation is mostly confused and incoherent, espe- 
cially as soon as they fall into excitement ; they are not clear 
about their position, and are without understanding for the 
occurrences in their surroundings. 



ISSUE— TERMINAL STATES 205 

Mood is sometimes jocular, but much more frequently 
irritable, morose, even threatening ; besides convulsive 
laughter furious outbursts of abuse with a tendency to 
violence occur. At the same time the patients are inaccess- 
ible, repellent, taciturn, or absolutely mute, sometimes for 
years ; they look away when spoken to, resist every interfer- 
ence, refuse food, avoid people, try to get away, stand at one 
particular door in order to rush out as soon as it is opened. 
They hide their face, creep under the bedcover, sit with their 
eyes closed, lie down under the bed, do not tolerate any 
clothes, stand naked or in their shirt beside the bed, or lie on 
the floor only wrapped in a coverlet. Many patients whisper 
low, unintelligibly to themselves, become mute as soon as one 
listens to them; others in walking always go a few steps 
backwards again. If told to do anything, they do not obey, 
at most once in a way they answer with a slight shake of the 
head. " We must not shake hands," declared a patient. The 
attitude of the patients is usually rigid, constrained, some- 
times quite odd, and is for a long time monotonously main- 
tained. An example of this is given in Fig. 35 ; the patient 
represented remained continuously in the same attitude. A 
patient got gangrene from holding his fist clenched. 

Besides the negativistic phenomena there are invariably 
impulsive actions, stereotypies and mannerisms as well. The 
patients throw away their food or their shoes, swallow glass 
and stones, give utterance to senseless sounds or bestial cries, 
pull out their hair, jump about with great leaps and suddenly 
stand still like a monument. They rub their heads keeping 
time, rock with their body or with their foot, make monotonous 
movements with their fingers, shake themselves, stamp on 
the ground, nod, spit. Others lie with the corner of the sheet 
or their fingers in their mouth, assume singular attitudes, shake 
hands with the fourth finger, stir up their food, speak lispingly 
or in a stilted manner, invent a peculiar spelling. Here also the 
capability for work is always very severely damaged, though 
many patients can still be trained to simple mechanical work. 

Prognostic Indications. 

At the present time it must still be considered doubtful 
how far the terminal states here described really represent in 
individual cases the last period of the development of the 
disease. For simple weak-mindedness, which signifies a kind 
of recovery with defect, it is distinctly enlightening and often 
confirmed by experience that, sooner or later, a fresh exacer- 
bation of the disease may follow and bring about a higher 
degree and another form of dementia. But also in the 



206 DEMENTIA PRECOX 

remaining forms changes in the condition are often possible, 
even after a number of years, usually in the sense of deteriora- 
tion. That is especially true of hallucinatory weak-minded- 
ness. Further we see, as described before, paranoid states 
not infrequently pass later into negativistic or manneristic 
dementia ; the same might be said of silly dementia which in 
certain circumstances even after a decade may be essentially 
changed by the appearance of stupor or of excitement. 

Drivelling, dull and manneristic dementia appear to be 
variable more according to degree than according to kind. 
In negativistic dementia, lastly, so long as well-marked nega- 
tivistic stupor exists, the possibility of considerable improve- 
ment is to be reckoned with, which now and then may appear 
even after the lapse often years. Petren reports the case of 
a patient who had to be tube-fed for nine years, but who yet 
after being ill for eleven years was so far restored again that 
he earned a living for himself and his family as a tailor and 
only showed still a certain irritability. It appears accordingly 
that in stupor there are fundamental changes which still after 
a very long time are capable of retrogression. But it is very 
difficult in individual cases to decide whether such a possibility 
still exists or not. It appears that in the cases which finally 
have become incurable, the severity and especially also the 
promptness of the negativistic reaction to interference relax 
considerably. This suggests that there is a loosening of the 
inner harmony between impressions, impulses and volitional 
actions as we formerly saw it as a fundamental disorder in 
dementia praecox. 

In the remaining forms also of the terminal states the 
point of time is difficult to determine from which onward the 
appearance of considerable improvement can no longer be 
expected. On the whole the prospects will be the more 
unfavourable the more those peculiarities are developed, 
which we. see in the foreground in the multitude of cases 
finally uncured. Among them there is especially the loss of 
emotional activity which characterizes the most severe forms 
of the disease, those that issue in dull dementia ; with it the 
connecting link falls away which unites rational action to 
perception and thought. Furthermore the development of 
fixed mannerisms and stereotyped movements is apparently 
to be regarded as an unfavourable sign ; they are a sign that 
the influence of healthy volitional action and inhibition on 
activity is no longer strong enough to suppress side-impulses 
and the tendency to repetition. Of specially bad significance 
is the appearance of simple rhythmical movements ; they 
seem only then to occur when through very deep-reaching 



ISSUE— TERMINAL STATES 207 

destruction of the volitional apparatus lower ancestral motor 
mechanisms acquire a certain independence. Lastly, the 
states of excitement and moodiness occurring periodically 
and abruptly are probably also of evil significance, as they 
very frequently make their appearance in the incurable 
terminal states. These also might indicate that the equili- 
brating mechanisms were disordered, which otherwise make 
the psychic life to some extent independent of the fluctuations 
of bodily conditions. 

We come therefore to the conclusion that the onset of 
incurable terminal states is announced chiefly by those 
disorders which signify the loss of mastery over volitional 
action, be it that the mainsprings of volition are broken, be it 
that the mechanisms are destroyed which make systematic 
co-operation of individual volitional actions possible. I 
would ascribe much less importance to pure disorders of 
intellect. They appear in general to be further removed 
froKi the point of attack of the morbid process, and therefore 
not so soon to signify incurable phenomena of decay. Not 
only may hallucinations and nonsensical delusions be again 
completely lost, but also incoherence of the train of thought, 
and indeed even marked confusion of speech. Only then 
when with continuance of these disorders emotional activity 
also gradually disappears, is one obliged to consider the 
hope of equilibrium being restored as very slight. 

The prognosis of individual cases is made essentially 
more difficult by the circumstance that it is not always easy 
to obtain absolute certainty about the existence of the above- 
mentioned symptoms. Indifference towards occurrences in 
the surroundings may also be simulated by negativism or 
by stupor. Only then when the patients, in spite of complete 
understanding and without a symptom of negativism, show 
no further interest at all in their fellow - patients, their 
relatives or their occupation, and accept quite indifferently 
threats or contradiction in regard to their delusions, may we 
conclude that there is a real annihilation of emotional 
activity. In the same way only the stereotypies which have 
been retained for long and have become quite rigid, and 
lastly, only those states of moodiness and excitement, which 
without external cause return abruptly with approximate 
regularity, and after very short duration disappear again in 
the same way, are to be taken into account in judging of the 
prospect of recovery. 

Frequently not without significance also for judging the 
condition is the behaviour of the body weight. As the rising 
of this in general signifies a disappearance of acute morbid 



2o8 DEMENTIA PRvECOX 

phenomena, it may announce either the beginning of im- 
provement or, on the other hand, the development of a final 
state of weakness. The decision between these two possi- 
bilities is furnished by observation of the psychic behaviour. 
If the disappearance of the disorders which hitherto have 
been dominant is combined with a return of emotional 
activity, accessibility, interest in the surroundings and the 
relatives, and need for employment, a favourable turn of the 
course of the disease may be reckoned on. But if the patients 
in spite of increase of body weight remain incoherent, unin- 
terested, silly, manneristic, inaccessible, the probability is 
very great that the disease has reached a final and unfavour- 
able conclusion. Whether the loss of the psychic pupillary 
reaction is of prognostic significance in the individual case, 
must in the meantime still remain undecided. At any rate 
there are demented patients enough in whom it is preserved, 
while in other cases it is already absent in the beginning of 
the disease. At the same time its disappearance seems tp be 
considerably more frequent in the terminal states. Zablocka 
states that difference in the pupils also seems to have a certain 
unfavourable significance. 

Lastly, if we put before ourselves the question by what 
circumstances the issue of the disease is determined, obviously 
the clinical form is in the first degree decisive. Racke 
thought the prospects of recovery by far the most favourable 
in what he delinwted as the "subacute paranoid forms," con- 
siderably more unfavourable in the " depressive," still worse 
in the " excited-confused " and in the " stuporous " forms. If 
we go back to our classification, we saw formerly that periods 
of improvement lasting a considerable time are principally 
observed in the excited and the catatonic forms, therefore by 
preference in the forms which have an acute commencement 
and course, while the simple, silly and paranoid forms of 
dementia prsecox which usually begin insidiously offer far less 
prospect of material remissions of the morbid phenomena. 

With regard to t\\Q final issue the relations are somewhat 
different. Slighter degrees of psychic decline are, it is true, 
likewise fairly frequent in the excited forms, but are also 
often the issue of depressive forms and of simple progressive 
dementia ; further we may perhaps also regard hallucinatory 
weak-mindedness, and at least a part of the paranoid states of 
weak-mindedness, as relatively favourable issues. On the 
other hand the catatonic forms, silly dementia, and the first 
group of the paranoid forms usually have with greater fre- 
quency profound psychic weakness as a result. Closer rela- 
tions between the clinical forms and definite terminal states 



ISSUE— TERMINAL STATES 209 

can scarcely be demonstrated. Yet dull dementia appears to 
be developed most frequently from silly, simple depressive 
and excited forms, while negativistic and manneristic states 
of weak-mindedness constitute the issue specially of the cata- 
tonic, the depressive-stuporous and certain paranoid forms. 
Those forms which begin with silliness are also characterized 
by it in their terminal states ; incoherence appears to char- 
acterize by preference the issue of the states of excitement. 
Lastly, hallucinatory and paranoid weak-mindedness comes 
essentially under observation as the conclusion of paranoid 
forms. 

According to Zablocka's statements the appearance of 
mutism of long duration and of stereotypies indicates the 
probability of a more profound dementia, and the same may 
be said of an insidious commencement of the disease. On 
the other hand Bleuler states that cases with considerable 
improvement after the first attack of the disease seldom 
become profoundly demented later. His further statement 
that acute forms show a greater tendency to very severe 
terminal states I can thoroughly confirm for catatonic forms, 
but for states of excitement only, with the limitation that 
here besides the frequent dull, manneristic or drivelling 
dementia, the issue in simple weak-mindedness is also very 
often observed. 

Of further influences, which may acquire significance for 
the issue of the disease, there might be mentioned predis- 
position^ while external causes in any case play no decisive 
part. Bleuler considers those cases more unfavourable in 
which from childhood up, abnormal qualities have appeared, 
and Zablocka also thinks that there is in them a stronger 
tendency to profound dementia. That becomes intelligible, 
if one assumes that in such cases through an inferior dis- 
position either there exists a lesser power of resistance to 
the morbid process, or the morbid process itself, develop- 
ing insidiously from childhood, has already generated those 
abnormalities. The last view would be supported by Bleuler's 
statement that inherited weakness does not exercise any 
influence on the prognosis. On the other hand, Mattauschek 
reports that dementia praecox has a more unfavourable course 
among Slavs and Jews than among Germans. 

The Age of the patients has a decided influence on the 
course of the disease. The forms which begin in the years 
of development are by preference states of excitement, 
especially those with a periodic course, then simple depressive 
forms, and certainly also insidious dementia (dementia 
simplex), morbid states which in general tend to have a 

O 



210 DEMENTIA PRyECOX 

milder course. Somewhat later silly dementia and the 
catatonic forms have their greatest frequency, that is, forms 
which are decidedly to be regarded as severe. Still later, 
depression with delusions is developed, likewise a form with 
an unfavourable course predominating. Lastly, in definitely 
advanced age the paranoid forms appear, which on the one 
hand lead not so very frequently to the most severe forms 
of psychic weakness, but on the other hand show very little 
tendency to essential improvement of the morbid state when 
it is once developed. It could, therefore, be approximately 
said that here with advancing age the ability to restore the 
equilibrium and repair the damage generated by the disease 
gradually diminishes, but that at the same time the work of 
destruction appears to spread less deeply. 

Sex. — There appear also to be certain relations between 
sex and the form of the disease. Men have a somewhat 
larger share in the unfavourable form of silly dementia ; 
women on the other hand have a greater tendency to paranoid 
forms, a circumstance which might, generally speaking, be 
connected with the greater frequency of paranoid morbid 
states in the period of involution in the female. Women are 
in a still greater majority in the states of excitement running 
a periodic course, but here there are not nearly enough 
statistics to hand ; otherwise one might in these forms be- 
ginning in youth think of the influence of the so strongly 
marked tendency in woman to a periodic course of normal 
as well as of morbid processes. 

The Time in which the development of an incurable 
terminal state is accomplished naturally fluctuates within 
very wide limits. For one thing the exact commencement 
of the morbid phenomena can often enough only be deter- 
mined with great difficulty, as all sorts of insidious changes 
have already for years been developing imperceptibly. But 
then, as already detailed, considerable improvement lasting 
a long time may make the course of the disease extraordin- 
arily slow. Lastly, it is often scarcely possible to mark 
the point of time, even merely approximately, at which the 
final stage of dementia is reached. Strictly speaking, one 
will never be quite certain here, as probably changes in the 
condition may still appear, and certainly for the most 
part in a downward direction. In spite of these difficulties 
so much may perhaps be said that as a rule, if no essential 
improvement intervenes, in at most two or three years 
after the appearance of the more striking morbid phenomena 
a state of weak-mindedness will be developed, which usually 
changes only slowly and insignificantly. But often enough 



ISSUE— TERMINAL STATES 211 

the unmistakable symptoms of dementia appear already 
within the first year, indeed even after a few months, though 
here a prodromal period of considerable length can never 
be excluded. Albrecht states that of his hebephrenic patients 
27 per cent., of his catatonics 19 per cent., reached their 
terminal state within the first year. 

Mortality. — Life is threatened only very slightly by 
dementia praicox. Kerner on the ground of researches in 
the institution at Rheinau comes to the conclusion that the 
mortality of patients with dementia praecox is somewhat 
greater than that of the healthy population of the same age. 
Here account must be taken of the fact that the patients 
in the institution on the one hand are in high degree pro- 
tected from many of the injuries of life, struggle for existence, 
alcoholism, syphilis, accidents, and lead a quiet life constantly 
supervised by medical skill, but that, on the other hand, the 
confinement, with the small space which it affords for exer 
cise, considerably lowers the tonicity of the body, and that 
the crowding of people together favours the development of 
tuberculosis. But of much greater importance is the circum- 
stance, that by the psychic disease itself conditions are 
created which are fitted to increase the mortality. Dull and 
negativistic dementia, but especially stuporous states, which 
often last for years, bring about more or less complete bodily 
inactivity with depression of the work of lungs and heart 
and of the whole metabolism ; in addition to that the 
patients by hiding away under the bedcover and obstinate 
resistance forcibly shut themselves off from the enjoyment 
of fresh air and often also take food very irregularly or 
of an unsuitable kind, or they may even for a long time 
have to be tube-fed. Other dangers threaten owing to the 
impossibility of treating suitably, because of restlessness or 
obstinacy on the part of the patients, bodily suffering caused 
by chance injuries in states of excitement or by damage 
which the patients infliet on themselves. The most frightful 
mutilations of themselves carried out often with incredible 
rapidity and energy, tearing out of eyes or tongue, self-castra- 
tion, are occasionally observed in- our patients. Also unex- 
pected suicide, especially in the first period of the malady, is 
not infrequent, and occurs sometimes without any recognizable 
cause also in patients who for long have been weak-minded 
and apparently quiet. 

But lastly, in certain circumstances the morbid process as 
such may also lead to death. Occasionally, though seldom, 
it is observed that in severe states of excitement of long 
duration a steadily progressive loss of strength gradually 



212 DEMENTIA PRECOX 

makes its appearance, which continues even when the 
patients become quieter and take abundant nourishment. 
Finally death ensues with extreme cardiac weakness and 
great sinking of the temperature without the autopsy 
showing any perceptible organic disease at all. It is 
customary to speak here of exhaustion which is thought to 
be caused by the restlessness, the profound disorder of sleep 
and the irregular taking of nourishment. But as further on 
we must assume a cause which generates all those disorders, 
the possibility must also be reckoned with, that the same 
cause directly threatens life perhaps by far-reaching injury to 
the body mechanisms. Less uncertain is the causation of 
death by the morbid process itself in those somewhat 
frequent cases, in which the death of the patients results at 
the height of severe excitement, accompanied by phenomena 
of cerebral irritation with convulsions or paralyses, sometimes 
with almost continuous seizures. According to the investiga- 
tions of Reichhardt it has become probable that here we 
have to do with an acute "cerebral oedema," with rapid 
changes of the brain which cause an enlargement of volume 
and therewith the appearance of fatal cerebral pressure. 
Now and then cases of sudden death ^ occur in stupor or in 
the terminal states, sometimes in a catatonic attack, some- 
times without any striking phenomena Fankhauser found 
in some cases of the last kind status lymphaticus. 

^ Giannelli, Rivista di patologia nervosa e mentale xiii. 4. 



CHAPTER VIII. 

MORBID ANATOMY. 

The morbid anatomy ^ of dementia praecox does not show 
macroscopically any striking changes of the cranial contents ; 
only occasional thickening and oedema of the pia are re- 
ported, the latter evidently a result of agonal processes. On 
the other hand, it has been shown that in the cortex we have 
to do with severe and widespread disease of the nerve-tissue. 
In some cases which succumbed in a condition of acute 
delirium and which are classed by him as catatonia, 
Alzheimer has described deep-spreading changes in the 
cortical cells, especially in the deep layers. The nuclei are 
very much swollen, the nuclear membrane greatly wrinkled, 
the body of the cell considerably shrunk with a tendency to 
disintegration. Similar findings have often been brought 
forward since then, also in cases which after psychic decline 
of considerable duration had succumbed to other diseases. 
Nissl invariably saw widespread cellular disease, which had 
led to considerable loss without, however, causing that 
extreme distortion and shrinking of the cortex which we 
have seen in paralysis. In the old cases which have reached 
a termination, Alzheimer found widespread changes in the 
cells which must be regarded as the terminal state of grave 
disease which has run its course, in particular sclerotic forms. 
Very frequently deposits of lipoid products of decomposition 
were found in the various tissue-cells, even already in quite 
young persons. With striking frequency were groups of 
nerve-cells observed, in which the basal processes appeared 
to be swollen and deformed by accumulation of fat. Lastly 
diffuse loss of cortical cells could also be established. All 
these most severe morbid residua could be demonstrated in 
marked predominance in the second and third cortical layers. 
Wada states likewise that the large pyramidal cells are 
comparatively less affected. Sioli was able to demonstrate 

^Alzheimer, Centralbl. f. Nervenheilk. , 1900,296; De Buck et Deroubaix, 
Le nevraxe vii. 2, 163; Zalplachta, Revista stintelor medicale 1906, 7-10; 
Agostini, SuU' analomia patologica dei centri nervesi della demenza primitiva., 
1907; Goldstein, Archiv, f. Psychiatric xlvi. 1062; Wada, Obersteiners Arbeiten 
xviii. 313. 



214 DEMENTIA PRECOX 

in connection with the destruction of the cells a great 
accumulation of lipoid disintegrated material in the cortex, 
in the tissue and specially round the vessels. He often 
found the fibrils still well preserved ; Moriyasu often found 
them disintegrated. Wada reports that the extra-cellular 
fibrils are profoundly changed, and Goldstein asserts that in 
particular the coarser fibrils are damaged. 

The ^//rt has a great share in the morbid processes. In 
the acute cases Alzheimer saw the presence of am(jeboid 
hyperplasia of neuroglia, accumulation of glia cells round 
the nerve-cells and morbid new formation of fibres, which 
"embraced" the cells in a peculiar way. Nissl observed 
especially in the deeper cortical layers numerous large glia 
cells undergoing involution, of a kind that occurs in normal 
circumstances only on the margin of the cortex. Specially 
striking further was the fact that everywhere glia cells 
were found with the bodies of the cell scarcely coloured, 
and with vesicular, peculiarly pale, very large nuclei, which 
often seemed to be closely applied to, or indeed to have 
penetrated into, the diseased nerve-cells, mostly at the base 
like the ordinary satellite nuclei, but also in other places. 
These structures could be demonstrated with greatest ease in 
the inner zone of the medullary border layer. According to 
Sioli the glia cells in the first cortical layer, then those in the 
deep layer of the cortex and in the medulla exhibit a strong 
tendency to morbid formation of fibres and to the protoplasm 
becoming coarse; in the medulla amoeboid j^lia cells were 
found in abundance. Eisath likewise saw increased fibre- 
formation, dark staining of the glia nuclei, and in the deeper 
layers increase of the granular substance of the glia, a few 
sickle-shaped satellite cells with disintegration of pigment, 
in the medulla degenerated, atrophic glia cells and sometimes 
increase, sometimes decrease, of fibre-formation. 

The niedullary fibres appear according to the findings of 
Goldstein, De Buck and Deroubaix somewhat thinned 
especially in the supraradial network ; Goldstein, Agostini, 
Gonzales, Moriyasu, Klippel, and Lhermitte describe slight 
loss of fibres in the tracts and changes in the anterior horn 
cells of the spinal medulla. By some investigators, Obregia, 
Klippel and Lhermitte, Doutrebente and Marchand changes 
in the vessels were also found, new formation of vessels, 
proliferation of vascular cells. As the vessels, however, 
as a rule, have no share in the morbid process, we have here 
probably to do with chance side-findings caused possibly by 
age, alcoholism or syphilis. Doutrebente and Marchand saw 
numerous nerve-cells in the embryonic stage of development; 



MORBID ANATOMY 



215 



Agostini also reports some traces of arrested development 
and residua of childish diseases. Mondio found in six cases 
anomalies in the convolutions, which he regards as signs of 
degeneration. Schroder from the same point of view describes 




Fig. 36. Nerve-cells surrounded by glia nuclei. 

in one case displacement of Purkinje cells and double nuclei, 
and also syncytial formations in the pyramidal cells of the 
cerebral cortex. 

The accompanying figures represent some of the most 
important findings in dementia praicox. The first two figures 
represent acute changes. In Fig. 36 a number of nerve-cells 
from the deep layers of the cortex are reproduced, which are 
surrounded as thickly as possible by numerous glia cells 



2l6 



DEMENTIA PR^ECOX 



recognizable by their dark nuclei, some of which have very 
much enlarged protoplasmic bodies. The distribution of 
decomposition products is represented in Fig. 37, \yhich is 
taken from the cortex of a stuporous patient who died sud- 
denly in a seizure. Two glia nuclei (^) are seen, round which 




Fig- 37- Fibrinoid granules in glia cells. 

are grouped radiating chains of fine granules ; these are 
fibrinoid granules which have accumulated in the far-branch- 
ing protoplasmic bodies of the glia cells which are otherwise 
not recognizable here. The lower glia nucleus lies on the 
nucleus of a nerve-cell («) still partially visible ; in the neigh- 
bourhood of the upper nucleus also there is a nerve-cell («). 

The chronic changes in the nerve cells are reproduced in 
the two following figures. In Fig. 38 three nerve-cells from 
the upper part of the third layer of a healthy frontal lobe are 
represented ; beside these there are two normal glia nuclei. 
In contrast to that three cells from the corresponding part of 
the cortex of a patient who died after long duration of 
dementia pnx'cox in his twenty-fifth year are seen in Fig. 39. 
The narrowed shrunken cells with dark, long-drawn-out 
nuclei and deeply stained processes exhibit the picture of 



MORBID ANATOMY 



217 



cell-sclerosis ; the tissue arranged as a network contains lipoid 
products of disintegration. Of the glia nuclei lying beside 
them one is unusually large ; the other two are small and 






Fig. 38. Normal nerve-cells with glia nuclei. 

darkly stained (pyknotic). In Figs. 40 and 41 also there are 
healthy and diseased nerve-cells placed in contrast. In two 
of the healthy cells and in one of the two glia cells lying 
between them there are only a few fine lipoid droplets. The 
drawings are from the third layer of the frontal lobes of a 
woman thirty-seven years of age who was mentally sound. 




Fig. 39. Sclerotic nerve-cells in dementia prsecox. 



In contrast we see the diseased cells, changed in the highest 
degree ; they were taken from the cortex of a man twenty- 
three years of age who had suffered for five years from 
dementia praecox. In consequence of the distortion of the 
cortical structure caused by the morbid process some of the 
cells are obliquely placed ; their nuclei are shrunken and 
elongated, their processes are recognizable for a long way. 
But above everything one sees the shapeless, turgid body of 
the cells and also the processes completely filled with lipoid 



2i8 DEMENTIA PR.CCOX 

products of disintegration. Here also there meet us two 
unusually large glia- nuclei along with a small dark one; the 
cell-bodies of these, which otherwise are not visible, show 
numerous lipoid granules. 

As in the clinical picture of the disease there are appar- 
ently also in the anatomical findings two different groups of 
processes, first the morbid disorders caused directly by the 
disease, and second the losses remaining as a consequence. 
To the first belong the changes in the cells, the formation of 
products of disintegration, the hyperplasia of glia, especially the 



I* 



i^j^ 




Fig. 40. Healthy nerve-cells. Fig. 41. Nerve-cells diseased in high degree filled 

with lipoid products of disintegration. 

appearance of amceboid glia cells ; to the second the destruc- 
tion of cells and fibres, the necrotic and involutionary pheno- 
mena in nerve-tissue and glia, the deposition of fat and 
pigment. According to whether it is a recent case relatively, 
an acute relapse of the disease, or an old case in the terminal 
state when the disease has long since run its course, the com- 
bination of anatomical changes will be different. 

It has been already mentioned that the loss is for the 
most part to be found in the second and third cortical layers. 
Whether it extends over wide cortical areas to the same 
degree, remains still to be investigated ; by some investigators, 
Mondio, Zalplachta, Agostini, De Buck and Deroubaix, 
Dunton, Wada, it is stated that it involves the frontal lobes 
and the area of the central convolutions, also the temporal 
lobes to a greater degree than the occipital cortex. Klippel 
and Lhermitte report atrophic changes also in the cere- 
bellum. 

In the remaining organs of the body in general only the 
findings resulting from the chance cause of death can be 



MORBID ANATOMY 219 

found. Dide, who looked for changes in the sexual glands, 
found these healthy, but on the other hand often saw fatty 
degeneration of the liver. Benigni and Zilocchi describe two 
cases with diffuse fatty degeneration in the liver, kidneys, 
heart, vessels, thyroid gland, and hypophysis. It must in the 
meantime remain undecided whether such findings have any 
further significance. 

Relation of Morbid Anatomy to the Clinical Picture. — 
If we now make the attempt to consider the relation of the 
anatomical findings which hitherto have been got, to the 
clinical picture of the disease, there are two points which 
might be considered significant, the distribution of the morbid 
changes on the surface of the cortex, and the share of the 
different layers of the cortex. If it should be confirmed that 
the disease attacks by preference the frontal areas of the 
brain, the central convolutions and the temporal lobes, this 
distribution would in a certain measure agree with our present 
views about the site of the psychic mechanisms which are 
principally injured by the disease. On various grounds it is 
easy to believe that the frontal cortex, which is specially well 
developed in man, stands in closer relation to his higher 
intellectual abilities, and these are the faculties which in our 
patients invariably suffer profound loss in contrast to memory 
and acquired capabilities. The manifold volitional and motor 
disorders, which extend partly to the harmonious working of 
the muscles, will make us think of finer disorders in the 
neighbourhood of the precentral convolution. As it does not 
go so far as paralyses or to genuine apractic disorders, and 
there are only indications occasionally of motor-aphasic 
disorders, we may assume, although as yet no investigations 
on the subject are to hand, that the actual motor discharging- 
stations are not attacked by the destructive process. On the 
other hand the peculiar speech disorders resembling sensory 
aphasia and the auditory hallucinations, which play such a 
large part, probably point to the temporal lobe being involved. 
Here also, however, there is no true auditory aphasia, but 
only a weakening of the regulating influence of clang-associa- 
tion on the movements of speech expression, perhaps also 
a loosening of the connection between the former and con- 
ceptions ; we must, therefore, imagine that the disorder is 
essentially more complicated and less circumscribed than in 
sensory aphasia. The auditory hallucinations, which exhibit 
predominantly speech content, we must probably interpret as 
irritative phenomena in the temporal lobe ; it might not be 
due to chance that we invariably observe them along with 
confusion of speech and neologisms. The phenomena of 



220 DEMENTIA PRECOX 

hallucinatory repetition and hearing of thought point to the 
relations between ideas and sensory areas being attacked by 
peculiar disorders. 

As the significance of the cortical layers is at present still 
almost wholly unknown, it will scarcely be possible to set up 
hypotheses with regard to the influence of the site of the 
morbid processes in definite layers, although it is certainly 
not indifferent for the form of the disease. According to the 
extended experience of Alzheimer we may assume that the 
permanent loss of nerve-tissue capable of work concerns 
preferably the second and the third layer of the cortex, 
therefore the smaller nerve-cells, though in the acute periods 
of the malady a severer attack of the deeper layers is simulated 
by the proliferation of glia which is there specially conspicuous. 
On the other hand the first terminal stations of the paths 
radiating from the sense-organs into the cortex and the large 
motor cells, in which we locate the origin of the pyra- 
midal tracts which make their way to the spinal marrow, both 
lie in the depth of the cortex the structure of which, moreover, 
still most resembles that of the cortex of the lower animals. 
In these layers, therefore, will the processes presumably take 
place, which correspond, on the one hand to the appearance 
of a sensory perception, on the other hand to the discharge of 
a motor impulse, or are immediately connected with these. 

In opposition to this we may ascribe to the upper small- 
celled layers such activities as are peculiar to the higher 
psychic stages of development since they reach their highest 
perfection in man, especially in the frontal lobes. Though it 
would not be suitable to put forward conceptions going into 
particulars about these relations, still it is easy to think before 
everything of the process of abstraction, which transforms 
perceptions to general ideas, sensations to emotions, impulses 
to permanent trends of volition. These abstract creations of 
the higher psychic activity are what the essence of the 
psychic personality is compacted of As a permanent deposit 
of the experiences of life they dominate the thought, feeling 
and will of man for long periods, and up to a certain degree 
make it independent of the experiences of the moment, which 
through it are reinforced, moderated, corrected, or in certain 
circumstances even shown to be false. One may probably 
with impunity lay stress upon the fact, that in dementia 
praecox apparently it is the loss of those permanent 
foundations of the psychic life, as they are created by 
abstraction, which influences the clinical picture often in the 
highest degree in incoherence of thought, in contradictory 
change of emotions, in impulsiveness of action. 



MORBID ANATOMY 221 

The small-celled layers extend in fairly uniform structure 
over nearly the whole surface of the brain. The hypothesis, 
therefore, is easy that besides the task of abstraction, perhaps 
in connection with it, they have also the task of mediating 
between the activities of the deeper layers which are more 
confined to circumscribed areas, especially sensory perceptions 
and volitional impulses. The real psychic elaboration of 
external experience, the linking of it on to past experiences, 
the critical judgment of it by means of formerly acquired 
standards, the connecting of it to new psychic structures, to 
conclusions and creative ideas, could even so be ascribed to an 
organ gathering things together in that way, as the prepara- 
tion for action by weighing values, the ripening of decisions 
on the ground of deliberation. It is evident that the activities 
named here must before everything else be regarded as 
foundations of the inner unity and consistency of the psychic 
life. The fact that the working of external influences is 
essentially determined by the permanent character of the 
personality concerned, and that in the other direction action 
represents the outflow of the whole experience of life, 
necessarily forces us to the assumption, that the organ of 
our psychic life must also contain mechanisms which mediate 
a general connection of all the psychic workshops among 
each other. Just the destruction of the psychic personality, 
of this inner harmony of all the parts of the psychic 
mechanism in perhaps even surprising individual activities 
is, as formerly demonstrated, the real fundamental disorder 
in dementia praecox. If Alzheimer's finding is proved to be 
invariably present, we might from it conclude with a certain 
probability that in the small-celled layers, that harmonious 
gathering into one of psychic activities takes place, the 
destruction of which characterizes dementia praecox. 

This hypothesis gains great support from the circum- 
stance, that in our disease the lower psychic mechanisms 
as a rule are comparatively little encroached on, corresponding 
to the slighter damage done to the deeper cortical layers. 
The power of purely sensory perception remains often fairly 
well preserved, as also the memory of perceptions, and 
acquired knowledge and skill. On the other hand judgment 
is lost, the critical faculty, the creative gift, especially the 
capacity to make a higher use of knowledge and ability. 
Pleasure and the lack of it are often perceived by the 
patients with the greatest intensity, but the sense of beauty, 
the joy in understanding, sympathy, tact, reverence, desert 
them, as also the intelligent, continuous emotional relations 
to the events of life. The patients may also exhibit volitional 



222 DEMENTIA PRECOX 

activity of the greatest strength and endurance, but they are 
wholly incapable of arranging their lives according to rational 
principles or of consistently carrying out a well-considered 
plan. We see, therefore, in all the domains of psychic life 
the ancestral activities offering a greater power of resistance 
to the morbid process than the psychic faculties belonging 
to the highest degrees of development, corresponding to the 
slighter damage done to the deeper cortical layers which 
are more like those of the lower animals, in contrast with 
those which only attain to development with the appearance 
of the most complicated psychic activities. 

The transparency of this relation is somewhat clouded 
by the fact, that memory being well preserved may make 
possible the continuance of individual capabilities which are 
much exercised. We may well assume that the site of both 
sensory and mechanical memory is to be sought for princi- 
pally in the deeper cortical layers, the former in the sensory 
centres, the latter in the areas which mediate the harmony 
of movements. The experience which has been formerly 
acquired is able up to a certain point to cover the destruction 
of the higher faculties, just so far as independent psychic 
activity may be replaced by acquired proficiency. Precisely 
work which is dependent on understanding is often served 
by associations of ideas and habits of thought which have 
been firmly laid down in forms of speech, while in the domains 
of the emotional life and of action an adjustment to the 
special conditions of the given moment is requisite in far 
higher degree. Perhaps there lies in this an essential ground 
for the clinical experience, that the disorders of dementia 
praicox usually appear here earlier and in more severe form 
than in intellectual activities. 

But further by the destruction of the harmonious person- 
ality which holds together and dominates the whole psychic 
life, there is given to the influence of ancestral mechanisms 
a free play which they could never otherwise acquire. To 
these namely I reckon the activities of automatic obedience 
and negativism, which are not set in motion by deliberation 
or moods, but appear and disappear irregularly. Stereotypy 
also, as a general expression of the facilitating action of 
volitional impulses, might come in here, as also the rhythmic 
movements characteristic of profound idiocy. Lastly in the 
mannerisms and derailments of action one might see the 
consequence of defective consciousness of purpose and defec- 
tive precision of volitional impulses, which makes them more 
easily accessible to all kinds of side-influences. Similarly 
neologisms and the manifold disorders in the structure of 



MORBID ANATOMY 223 

speech may probably be connected with loosening of the 
connection between abstract ideas, speech sounds and speech 
movements and with defective characterization of speech 
formulae ; all these are disorders which may be brought 
under the general point of view above discussed without 
special difficulty. In the roughest outlines, therefore, clinical 
experience and anatomical findings in dementia prajcox may 
with certain presuppositions be brought into agreement to 
some extent. It must naturally be left to the future to 
decide whether and how far such considerations stand the 
test of increasing knowledge. 



CHAPTER IX. 
FREQUENCY AND CAUSES. 

Dementia praicox is without doubt one of the most 
frequent of all forms of insanity. Its share in the admissions 
to a mental hospital is naturally subject to very considerable 
fluctuations, not only according to the delimitation of the 
morbid picture, but also specially according to the conditions 
of admission. With us approximately lo per cent, of the 
admissions might belong to it, while the proportion in 
Heidelberg amounted to nearly 15 per cent., because there, 
through formalities which made things difficult, a large 
number of slight cases of other kinds were kept out. 
Albrecht states the frequency for Treptow at 29 per cent. ; 
to the real mental hospitals only those patients go, who are 
absolutely in need of institutional treatment, and the cases of 
dementia prnecox are in the first ranks of these. As the 
patients neither quickly die off like the paralytics, nor 
become in considerable number again fit for discharge 
like the manic-depressive cases, they accumulate more and 
more in the institutions and thus impress on the whole 
life of the institution its peculiar stamp. In the private 
institutions with a smaller number of admissions the share of 
our patients may in the total amount rise to 70 or 80 per cent. 

The Causes of dementia praecox are at the present time 
still wrapped in impenetrable darkness. Indubitably certain 
relations to age exist. The very great majority of cases 
begin in the second or third decade ; 57 per cent, of the 
cases made use of in the clinical description began before 
the twenty-fifth year. This great predisposition oi youth led 
Hecker to the name hebephrenia, " insanity of youth," for the 
group delimited by him ; Clouston also, who spoke of 
an " adolescent insanity," had evidently before everything 
dementia praecox in view, although he did not yet separate 
it from the manic-depressive type which likevvi.se often begins 
about this time. Hecker was even inclined to regard the 
issue of his hebephrenia just as an arrest of the whole 
psychic life on the developmental stage of the years of 
puberty. In fact, we find in silly dementia at least many 



FREQUENCY AND CAUSES 225 

features which are well known to us from the years of 
healthy development. Among these there is the tendency to 
unsuitable reading, the naive occupation of the mind with 
the " highest problems," the crude " readiness " of judgment, 
the pleasure in catch words and sounding phrases, also 
sudden change of mood, depression and unrestrained merri- 
ment, occasional irritability and impulsiveness of action. 
Further the desultoriness of the train of thought, the half- 
swaggering, boastful, half-embarrassed, shy behaviour, the 
foolish laughing, the unsuitable jokes, the affected speech, 
the sought-out coarseness and the violent witticisms are 
phenomena which in healthy individuals, as in the patients, 
indicate that slight inward excitement which usually accom- 
panies the changes of sexual development. However, we 
shall not yet be able to conclude from these similarities that 
there are causal relationships between dementia praecox and 
puberty, as a limitation of the disease to the time of develop- 
ment does certainly not take place. 

The diagram, Fig. 42, represents the distribution of 1054 
cases with regard to age. The first striking thing there is, 
that the commencement of the malady for a certain percent- 
age of the cases is placed in the earliest years of life. It has 
to do here with a group of patients in whom already from 
childhood upwards a considerable degree of psychic weakness 
existed, although the more striking morbid phenomena 
only later, perhaps in the third decade, became noticeable and 
now led to fairly severe dementia. As there dementia 
praecox was in a certain manner grafted upon an already 
existing disease, we speak in such cases of an " engrafted 
hebephrenia." The proportion taken here of 3*5 per cent, is 
probably much too small, as only the most severe instances 
of that kind of case were separated out. Slighter divergencies 
of the most varied kind occurred moreover very frequently, 
a circumstance to which we shall later return. At this point 
it must already be emphasized that the determination of the 
point of time at which the disease began, is often very 
uncertain and arbitrary owing to the development being so 
frequently insidious. If it were wished to apply a very strict 
standard here, the whole diagram of age would certainly be 
dislocated not inconsiderably towards youth. 

The decrease in the percentage between the tenth and the 
fifteenth year is in so far artificial, that this number is not 
directly comparable with the number of engrafted hebephrenias 
existing from youth up. From that time on we see the 
frequency of dementia praecox increasing with extraordinary 
rapidity, more than two-thirds of the cases begin between 

P 



226 



DKMF.XTIA PR/ECOX 



the fifteenth and the thirtieth year, a quarter between the 
twentieth and twenty-fifth year. However, there can be no 
talk of an inviolable connection of dementia pr.xcox with the 
period of youth. We see the vertical lines of the diagram 
fall off fairly quickly, it is true, but yet with regularity, and 




Fig. 42. Percentage distribution of 1054 cases of dementia 
precox according to age. (J = years.) 

a not inconsiderable number of cases still reach development 
in the fourth, fifth and even in the sixth decade. 

It must be allowed here that the objection is suggested 
by the great excess of cases among the young, that the ca.ses 
apparently beginning late had in reality begun insidiously 
much further back, though the more striking morbid mani- 
festations only became noticeable after the lapse of many 
years and even decades. In general this objection is justified. 



FREQUENCY AND CAUSES 227 

Without doubt, especially in vagrants and criminals, a change 
of personality may gradually develop in youth, the morbidity 
of which is only recognized much later, when the known 
phenomena of dementia pnecox become associated with it, 
auditory hallucinations, delusions, states of excitement or 
stupor, incoherence, mannerisms. However, it would hardly 
do in some respects to set aside the share of the more 
advanced ages in dementia prrecox because of such considera- 
tions. The number of cases, the commencement of which 
would have to be displaced more or less far back, would in 
any case up to the fortieth and forty-fifth year be so large 
that it would be necessary to have uncommonly conclusive 
arguments to justify such a proceeding. Such arguments, 
however, are actually not forthcoming. So long as the view 
represented by Hecker for hebephrenia held, that there 
existed close causal relations between dementia praecox 
and puberty, the attempt could be made to find another 
explanation for the cases which did not fit this, or to separate 
them. Experience has, however, meantime taught that the 
greatest frequency of the cases falls at an age in which sexual 
development is essentially excluded. If already by that a 
dependence, in the narrower sense really causal, of the disease 
on the processes of puberty becomes improbable, it may 
further be pointed out, that we also very frequently see manic- 
depressive insanity begin at the end of the second, or in the 
beginning of the third decade, a circumstance which only 
admits of the interpretation that at this age the tendency to 
psychic disease is in any case specially great. 

The view here represented receives further support from 
the fact that, even if in the first place we leave engrafted 
hebephrenia wholly apart, cases occur already in childhood, 
which with the greatest probability we may classify as 
dementia praecox. Long ago I brought forward the hypothesis 
that certain, not exactly frequent, forms of idiocy with 
developed mannerisms and stereotypies might be early cases 
of dementia praecox. Weygandt -has not accepted this 
interpretation, as he asserts that the phenomena mentioned 
merely signify the appearance of childish forms of movement 
with inhibition of the higher development of volition by some 
or other morbid process. With this view already formerly 
developed by myself I can agree so far as it concerns the 
peculiar rhythmic movements of idiocy. I might take the 
view indicated of the sucking reflex also, which appears in 
very severe dementias (paralysis, Alzheimer's disease), and 
further of certain springing, rubbing " movements of suck- 
lings " which are observed in young paralytics. On the other 



228 



DEMENTIA PRECOX 



hand, the swaggering manners of some idiots, and likewise 
many stereot)'pies of attitude and movement which are 
connected with these, and lastly negativistic features which 
accompany them, e.g., permanent repellent inaccessibility to 
all attempts at approach, appear to me to have no relation at 

all to general childish peculi- 
arities but much rather to belong 
to the well-known morbid picture 
of dementia prjtcox. One of my 
patients had the habit of re- 
peatedly hitting his plate with 
his fork, waving his hat, dipping 
his bread again and again into 
his cup, scraping all round his 
roll, doing everything twenty or 
thirty times. A patient aged 
twenty-three years is represented 
in Fig. 43, who was from child- 
hood idiotic, dull, inaccessible, 
but otherwise clean, who carried 
out incessant, senseless, spread- 
ing movements with his hands. 
Complete certainty about the 
significance of such observations 
will, it is true, only be obtained 
by anatomical investigation. I 
may, however, point out that in 
one of my cases, the beginning 
of which reached back into the 
fourth year, and in which an 
extremely characteristic negativ- 
istic dementia had come into 
existence, the patient's mother 
also exhibited the picture of 
dementia prscox. 

Recently Sante de Sanctis^ 
has described under the name 
of " demenza precocissima " a 
series of morbid conditions 
observed in young children, which are accompanied by 
" catatonic " phenomena ; some of these cases are cured, but 
others issue in psychic weakness of greater or less degree. 
As he himself emphasizes, it can scarcely be decided at 

' Sante de Sanctis, Rivista ital. di neuropat., psicliiatria ed elettroterap ii. 3 ; 
Folia neurolofjica ii. 9; iii. 395; Weygandt, Zeitschr. f. d. Erf. d. jugendl. 
Schwachsinns i. 311. 




1-ig. 43- 



Idiot with manneristic 
movements. 



FREQUENCY AND CAUSES 229 

present how far the cases described belong to dementia 
prascox or to other forms of disease, among which indeed 
specially hysteria and infections, also syphilitic cases might 
come into consideration. However, the clinical agreement of 
some morbid states, which develop in the first or at the 
beginning of the second decade, with the dementia praicox of 
adults, in phenomena, course and issue is so apparent, that 
there can be no reasonable doubt about the relationship. I 
have myself observed several such cases and Racke and Vogt 
also have communicated some. Lastly, Heller has described 
as "dementia infantilis" cases which begin in the third or 
fourth year, sometimes run their course violently, sometimes 
insidiously, and issue in profound dementia with stereotypies 
and mannerisms. Here also we shall be obliged to think of 
the probability that at least many of these cases belong to 
dementia praecox. 

If in the interpretation of the morbid pictures appearing 
in earliest childhood we find ourselves often on ground at 
present still rather insecure, the same applies to the cases in 
the years of involution, which run their course according to 
the picture of dementia praecox. Here without doubt there 
are on the one hand cases, which according to our present 
knowledge cannot by any means be separated from the 
forms beginning earlier, which we, therefore, may term 
genuine " late catatonias." ^ Petren observed twenty-four 
cases of catatonia after the fortieth year, among them six 
between fifty and fifty-five, one of fifty-eight and one 
of fifty-nine years of age. Schroder also quotes a case 
which began at fifty-nine years. Zweig has brought together 
thirteen cases between the thirtieth and fortieth year and 
five cases after the fortieth, and arrives at the result, that 
they correspond in general to those of a younger age ; only 
the prognosis appeared to him to be comparatively favour- 
able, a conclusion for which the number of his observations 
is by no means sufficient, and which in Zablocka's com- 
munications finds no confirmation. It is very noteworthy 
that Schroder found four cases among sixteen late catatonias, 
in which twelve to twenty-five years previously very slight 
attacks, mostly states of depression, had preceded. The 
hypothesis formerly touched on, that it may here sometimes 
be only a case of the flaring up of a morbid process reaching 
far back in an inconspicuous form, finds in this experience a 
certain confirmation. Bertschinger also has pointed out this' 
possibility. Petren reports a case which at nineteen years of 

^ Sommer, Zeitschr. f. d. ges. Neurol, u. Psychiatric, i. 533. 



230 DEMENTIA PR^ECOX 

age passed through an attack of hebephrenia and recovered 
with defect, and then at the age of forty-four fell ill again. 

It must meantime be acknowledged that specially in the 
years of involution we not at all infrequently meet with 
cases, the clinical judgment of which even now meets with 
the greatest difficulties. Here it has to do at one time with 
cases which run their course with intense and anxious states 
of excitement and depressive delusions, also with catatonic 
symptoms, automatic obedience, inaccessibility, resistance, 
stereotyped attitudes and movements, and issue with com- 
parative rapidity, sometimes even after a temporary improve- 
ment, in profound psychic decline; at another time it 
is a case of paranoid forms. I consider it probable that here 
we have partly to do with morbid processes which do not 
belong to dementia praecox, although a satisfactory delimita- 
tion and especially a decision in individual cases at present 
is still scarcely possible. So far as the purely clinical view 
allows us, I have made the attempt in the discussion of the 
presenile and paranoid cases to fix some points of view for 
new morbid pictOres, An essential hindrance to the success 
of such attempts lies, however, in the circumstance, that the 
clinical forms of dementia praecox not only exhibit in them- 
selves an extraordinary variety, but that they also, as 
formerly mentioned in detail, are distinctly influenced by 
age. The decision as to which morbid disorders of the age 
of involution are to be reckoned with dementia praecox and 
which are to be regarded as psychoses of another kind, will 
therefore always depend on the question, how far the 
differences in the form of the clinical phenomena are con- 
ditioned by the character of the morbid process and how far 
by the changes of advancing age in the personality. 

The difficulties here touched on have caused Stransky, 
under the term "dementia tardiva,"^ to delimit certain 
paranoid cases of the years of involution with indications 
of catatonic features particularly in women as a special 
clinical form. Hallucinations, change of mood without very 
severe dulling of emotions, passing states of lively excite- 
ment, delusions without systematic elaboration, indications 
of catatonic features characterize the morbid picture. It 
must remain for the future to decide whether dementia 
tardiva represents a clinical entity, or whether, as I for 
the present consider more probable, it must be broken up into 
various groups according to the points of view indicated. 

Sex. — The male .sex appears in general to suffer .some- 
what more frequently from dementia pr.-ecox than the 

^ Stransky, Monatsschr. f. Psychiatric u. Neurol, xviii. Erg.-Heft. 



FREQUENCY AND CAUSES 231 

female ; among the 1054 cases utilized for our age-diagram 
there were 57*4 per cent. men. In the individual clinical 
forms meantime, as we have formerly seen, the share of the 
sexes exhibits not inconsiderable differences. The same 
holds good for the different ages, as the following table of 
the number of men in the different periods of life shows: — 

Age . . — 10 — 15 — 20 — 25 — 30 — 35 —40 — 45 — 50 — 55—60 
Men per cent. 70*3 500 658 63-6 579 50-4 60-4 343 540 33-4 00 

Engrafted hebephrenia appears therefore to be more 
frequent in the male sex ; but in the next period both sexes 
are attacked in the same degree. After the fifteenth year 
the male sex predominates greatly, then less, till between 
the thirtieth and the thirty-fifth year, equality, though only 
temporarily, is again reached. After the fortieth year women 
predominate especially at the most advanced ages, but the 
numbers from which the percentages are taken after the 
forty-fifth year are too few to be of use. It may be 
mentioned, however, that Schroder found among his "late 
catatonias " three men and thirteen women ; Sommer also 
emphasizes the predominance of the female sex. Considera- 
tion of the figures might in any case show at least, that the 
tendency of the female sex to attacks of dementia praecox, 
which on the average is somewhat less, experiences a certain 
increase in three different periods of life, before the fifteenth, 
between the twenty-fifth and thirty-fifth, and after the fortieth 
year. There will certainly be a temptation here to think .of 
sexual development which is earlier in the woman, of the 
time of the work of reproduction and of the years of 
involution. 

General Conditions of Life. — Since attention has been 
drawn to the morbid picture of dementia praecox, it has 
been shown that in all civilized nations it comes under 
observation in approximately the same forms and everywhere 
accounts for the greatest number of the permanent inhabi- 
tants of institutions. As the progressive increase of these 
patients seemed to prove most obviously the increase of 
insanity, it was easy to think of dementia praecox as a 
product of the injuries to which the progress of civilization 
and its unpleasant accompaniments exposes our mental 
health. Mental over-exertion, especially in the years of 
development, on the other hand degeneration, were frequently 
regarded as the causes of the malady. It appeared to me, 
therefore, of especial importance to ascertain whether the 
disease appeared also in nations, which live in quite different, 
and especially more simple and more natural conditions, A 



232 DEMENTIA PRvECOX 

yisit to the institution in Singapore at once showed me that 
in the most different constituent parts of the mingling of 
nations there, among Chinese, Tamils, Malays, there were 
clinical pictures to record which wholly resemble the forms 
of dementia pra;cox known to us. The later more exact 
investigation in the institution Buitenzorg brought out the 
result that the greatest number of the inmates there, con- 
sisting of Malays, Javanese, Sundanese and Chinese all 
thrown together, almost 80 per cent., presented morbid 
pictures about which it could scarcely be doubted that they 
belonged to dementia pra;cox. There were, it must be 
admitted, in the character of the individual features very 
remarkable differences from the forms familiar to us ; the 
disease began for the most part with states of confused 
excitement, which then with comparative rapidity led to 
drivelling dementia with incoherence, exalted mood, loquacity 
and mannerisms. Since then the frequent occurrence of 
dementia prcxcox in the most different regions of the world 
has been confirmed ; Koichi Miyake reports that it occurs in 
Japan just the same as with us, only with less tendency to 
states of depression. 

If we must therefore seek the real cause of dementia 
praecox in conditions which are spread over the whole world, 
which thus do not lie either in race or in climate, in food or 
in any other general circumstances of life, we are still not 
able to say anything as to whether the factors mentioned 
have not perhaps a furthering influence on the development 
of the disease, as reliable statistical facts on this point have 
not been collected. We know nothing about the relative 
frequency of dementia pra.'cox in individual nations, in 
different conditions of life, in town and country, at different 
times. Only so much may be said, that the disease is prob- 
ably extremely old, as indeed the descriptions of the old 
physicians often unmistakably point to the clinical pictures 
familiar to us. 

Hereditary Predisposition. — Of the causal conditions of 
dementia praecox accessible to our investigation at present 
hereditary predisposition ^ must next be named. The figures 
stated for this point vary considerably among themselves, 
evidently according to the extent which is attached to the 
idea of heredity, as also according to the accuracy of the 
information which can be got about the families of the 
patients. Schott finds hereditary taint in 52 per cent., 
Lukacs in 53*8 per cent, Meyer in 54 per cent, Karpas in 

' Levi-Bianchini, Rivista sperimentale di freniatria xxix. 558; Berze, Die 
hereditaren Beziehungen der Dementia praecox, 1910. 



FREQUENCY AND CAUSES 233 

64 per cent., S^rieux in 70 per cent., Wolfsohn and also 
Zablocka in 90 per cent, of the cases. I had myself found 
forrtierly in Heidelberg general hereditary predisposition to 
mental disorders in about 70 per cent, of the cases in which 
about this point reliable statements were to hand. As by 
this restriction it naturally resulted that a certain selection 
was made, the proportion might be somewhat too high. 
Among the 1054 cases made use of above there were 538 per 
cent, in which the family history gave support to the assump- 
tion of hereditary taint. This figure is certainly too small, 
because in numerous cases the information about the ancestors 
of the patients was very incomplete. Perhaps it is possible 
to get somewhat more reliable figures if one limits oneself to 
direct heredity, that is to the occurrence of mental disorders, 
suicide or severe brain diseases in the parents, as about this 
question it is easiest to get trustworthy statements. Within 
this limitation there was found a direct taint in 337 per cent, 
of the cases, a number which on the grounds named must 
still be regarded as too low ; that appears also from the fact 
that the admissions in Heidelberg with their more complete 
previous histories yielded a higher value than the patients 
admitted often without any information in the city of Munich. 
But to that must be added that in 7*9 per cent, of the 
cases alcoholism in one of the parents was present ; this 
figure contrariwise is for Munich somewhat higher than for 
Heidelberg. In 2 per cent, of the cases lastly besides the 
direct taint of mental disorders alcoholism had also to be 
recorded in one of the parents. 

If these figures are compared with those got by Diem, 
it results that the taint from the morbid condition of the 
parents here taken into consideration is perhaps 10 per cent, 
higher than in mentally healthy individuals, and therefore 
causal relations must be regarded as probable. To the same 
view must the experience lead, that dementia praecox not 
at all infrequently is familial^ ftiost often appearing in 
brothers and sisters, more rarely in parents and children, 
as the disease, because of its early development and its 
serious phenomena, encroaches on the reproductive capability 
to a high degree. I know a very great number of cases 
in which several brothers and sisters were attacked with 
dementia praecox, sometimes in startlingly similar ways ; once 
three members of the same family were admitted very shortly 
one after the other. Schwarzwald ^ describes three series 
of cases, in which each time three sisters, and one in which 
five sisters were attacked with the symptoms of dementia 
^ Schwarzwald, De la demence precoce familiale. Diss. 1907. 



234 DEMENTIA PRECOX 

pr.-ccox. Frankhauser reports twenty-eight pairs of brothers 
and sisters who succumbed to the same malady. Not in- 
frequently one learns further that among the brothers and 
sisters of the patients there are found striking personalities, 
criminals, queer individuals, prostitutes, suicides, vagrants, 
wrecked and ruined human beings, all being forms in which 
more or less well -developed dementia pra^cox may appear. 

If such cases serve as evidence of a similar morbid pre- 
disposition, on the other hand, however, it also often occurs 
that among the members of some families disorders of quite 
another kind appear, epilepsy, hysteria, manic-depressive 
insanity. The comprehensive investigations, which Riidin 
has carried out about the families of our patients, have in 
the frequency of the familial occurrence of dementia praecox 
likewise made clear the important part played by hereditary 
predisposition. Riidin on the ground of his researches comes 
to the conclusion that dementia prnecox is probably trans- 
mitted according to Mendel's law and indeed as a recessive 
characteristfc. He has as evidence the great predominance 
of collateral and discontinuous inheritance compared with 
direct transmission, its increase in in-breeding and the special 
numerical ratio of those attacked in individual families to 
those who remain healthy. He finds that in the families 
attacked there comes under observation with relative fre- 
quency besides dementia prrecox a series of other anomalies, 
specially manic-depressive insanity and eccentric personalities. 
While the latter are probably for the most part to be regarded 
as " latent schizophrenias " and therefore essentially the same 
as the principal "malady, the relations to manic-depressive 
insanity are still not clear. Riidin found that manic-depres- 
sive parents not at all infrequently have children with 
dementia praecox, while the reverse case belongs to the rare 
exceptions unless there also exists inherited predisposition 
to manic-depressive insanity from the other side. 

Injury to the Germ. — Besides heredity, however, still 
other influences may apparently determine the appearance 
of dementia praecox. That is proved according to Riidin's 
experience first by the fact that first-born and late-born, also 
last-born, individuals are attacked by the malady with 
comparative frequency. Further it was shown that not 
infrequently immediately before or after the birth of the 
individual attacked there have occurred miscarriages, dead- 
born children, premature births ; or children with small 
vitality or with bodily or mental defects may have been born. 
The assumption is suggested by such observations that 
influences injurious to the germ might play a certain part 



FREQUENCY AND CAUSES 235 

in the origin of dementia praecox. Further evidence for that 
is given by the observation, confirmed by Riidin.that alcoholism 
is reported in the parents with striking frequency ; he found 
it at least sixty times in 300 accurately investigated cases. 
Wolfsohn saw chronic alcoholism in one of the parents in 
a fourth of the cases, while I could demonstrate it in my 
patients often with incompletely known previous history 
in any case in 10 per cent. One may accordingly assume 
that parental alcoholism probably exercises a certain influence 
on the development of dementia prnecox in the children, 
a connection which might be caused by injury to the germ. 

In the same sense we may probably interpret the state- 
ments made by Hirschl and Pilcz about the occurrence of 
syphilis in the parents of our patients. Pilcz reports that in 
416 cases of dementia praecox he had found tabes in 5 per 
cent, of the parents, in manic-depressive insanity on- the 
other hand only in 0'6 per cent. In the parents of forty-four 
hebephrenic patients paralysis was found twenty-three times, 
in those of twenty-seven catatonics five times ; also in the 
brothers and sisters of our patients paralysis was observed 
with striking frequency and in those of the paralytic often 
dementia praecox. In the parents of my patients I got 
information about syphilis only in 4 to 5 per cent. ; further it 
has not hitherto struck me that the children of paralytics are 
attacked specially often by dementia praecox; among 124 
such children of whom certainly only sixty-seven had passed 
their tenth year, and twenty-nine their twentieth year, two 
suffered from dementia praecox. On the other hand Klutscheff 
reports that in sixty cases of dementia praecox he has found 
in 4r6 per cent, signs of hereditary syphilis. As, however, 
otherwise there is no evidence of any kind for the assumption 
, that dementia praecox may be directly caused by hereditary 
syphilis, confirmation of such statements might probably 
only point to a general injurious action of parental syphilis 
on the germ. In each case investigation would be necessary, 
and with the help of serological procedure comparatively 
easy to accomplish, how far the traces of syphilis can really 
be demonstrated in the parents of our patients; the "stigmata" 
are, as is well known, extraordinarily deceptive. 

Personal Idiosyncrasy. — For the view that in the origin 
of dementia praecox degfneration plays a part, the circum- 
stance is usually brought forward that in the patients from 
the beginning, physical and psychic signs of degeneration are 
frequently found. Saiz^ states the frequency of such physical 
abnormalities, which are usually regarded as the expression 

^ Saiz, Rivista di freriiatria sperimentale xxxviii. 364. 



236 DEMENTIA PR/ECOX 

of degeneration, as 74 per cent. Considering the great 
elasticity of the limits, which in ascertaining such facts must 
be allowed for, it is scarcely possible to set a value on the 
figures. But it corresponds well enough to the general 
experience that in patients with dementia pra^cox all sorts 
of physical abnormalities exist with striking frequency, 
especially weakliness, small stature, youthful appearance, 
malformation of the cranium and of the ears, high and narrow 
palate, persistence of the intermaxillary bone, abnormal 
growth of hair, strabismus, deformities of the fingers or 
toes, polymastia, defective development and irregularity of 
the teeth and the like. Here is the place to add the not 
infrequent occurrence of convulsions in childhood, of 
obstinate nocturnal enuresis, of frequent headaches, sensitive- 
ness to alcohol, tendency to delirium in slight fever. 

But much more important than the physical signs of 
degeneration, which in similar guise appear in many other 
forms of insanity, appears to me the fact that in a consider- 
able number of cases definite psychic peculiarities have come 
under observation in our patients from childhood up. 
Schultze states that 50 to '70 per cent, of the patients were 
from the beginning psychopathic, and exhibited a shy, quiet, 
or specially in the female sex, an irritable, capricious 
character. Karpas found among his patients that 68 per 
cent, were psychopaths ; Schott reports that 28 per cent, 
of the patients were quiet and reserved. 

I also have examined minutely the previous history of 
my patients for the occurrence of striking psychic predisposi- 
tion and can in general confirm the statements of the 
investigators quoted, though I would abstain from giving 
definite figures because of the incompleteness of the 
information which is forthcoming at present. It was 
mentioned with very special frequency, particularly in the 
male sex, that children were mostly concerned who always 
exhibited a quiet, shy, retiring disposition, made no friend- 
ships, lived only for themselves. Of secondary importance, 
and more in girls, there is reported irritability, sensitiveness, 
excitability, nervousness, and along with these self-will and a 
tendency to bigotry. Then a smaller group of children, 
mostly boys, is noticeable, who from childhood up were lazy 
and restless, disliked work, were inclined to nasty tricks, did 
not persevere anywhere, and then became vagrants or 
criminals. Somewhat in contrast to that are those patients, 
likewise belonging rather more to the male sex, who were con- 
spicuous by docility, good nature, anxious conscientiousness 
and diligence, and as patterns of goodness held themselves 



FREQUENCY AND CAUSES 237 

aloof from all childish naughtiness. Intellectual endowment 
I found among my patients in Heidelberg, who were in more 
favourable circumstances for such investigations, in 17 per 
cent, of the cases stated as excellent, in about one-third of 
the cases as moderate, in 7 per cent, as poor. Evensen puts 
down 67 per cent, of his patients as being above the average, 
22 per cent, as poorly endowed ; Plaskuda puts down 15 per 
cent, as from childhood up limited. Schott states that 28 per 
cent, of his patients learned with difficulty, 40 per cent, on 
the other hand were good to very good scholars, and Levi- 
Bianchini attributes to 6 per cent, of his patients great, to 
60 per cent, medium, and to 24-4 per cent, slight endowment. 

In view of these experiences the question is raised in 
what relation the psychopathic abnormalities, which with 
striking frequency precede the development of dementia 
praecox, stand to the later disease, and especially whether 
they are only the expression of constitutional injuries which 
lower the power of resistance to the cause of dementia praecox, 
or whether it is a case of the first indications of the disease 
itself reaching back into childhood. For the answer to this 
question the circumstance seems to me to be of authoritative 
significance, that at least a part of the psychic peculiarities 
quoted exhibits the greatest resemblance to those disorders 
which we can establish in the incomplete remissions as 
well as in the cures with defect of our patients. In numerous 
cases we see here as a residuum of the disease in persons 
formerly not at all remarkable, the quiet, shy, retiring ; 
the indocile, stubborn ; the irritable, sensitive ; or the harm- 
less, good-natured conduct develop, as it is described in 
changing characters in the previous history of so many 
patients. Further, it must be pointed out that we not at 
all infrequently see a change in the personality, in the sense 
here indicated, take place first in the later years of childhood, 
but many years before the real onset of dementia precox. 
This experience may probably only be interpreted as 
a sign that the morbid process, which occurs here and 
first begins insidiously, is able to cause the same peculiarities 
which we see so frequently precede its appearance from 
childhood onwards. 

Here perhaps the objection may be made that the peculi- 
arities which meet us in the previous history of our patients 
could also be found in similar guise in any other group of 
people taken at random, and that they on the other hand 
are too varied to be the expression of one and the same 
morbid process. It must at once be admitted that the first 
objection is justified ; it would be quite necessary for the 



238 DEMENTIA PRECOX 

right appreciation of the circumstances to carry out similar 
investitjjations in other forms of disease also, but especially 
also in healthy individuals. We shall later have to discuss 
the results, which have been got up to now, of such investiga- 
tions in epilepsy and in manic-depressive insanity; they 
show that the previous history of the patients here does yield 
essentially abnormal features. It is true that there are also 
certain points of agreement ; but we may not leave out of 
account that our characterization of personal qualities at 
present is still very rough, that, therefore, under the same 
term, which is used by the relatives for the description of 
the former conduct of our patients, perhaps a series of wholly 
different characteristics is comprehended. If this source of 
error is appreciated, the impression is, as it appears to me, 
so overpowering, which is got from the statements, always 
the same, of the relatives about the former personality of 
our patients, that there cannot well be any doubt about the 
striking frequency of very definite predisposition in the 
previous history of dementia pra^cox. But the differences, 
the very contrast, of these peculiarities finds its exact counter- 
part in the differences of the clinical pictures, of the terminal 
states, and of the variations observed in the remissions. It 
is indeed easy enough to bring the reserved or stubborn 
conduct of the children, who are attacked later, into nearer 
relation with the negativism, their capriciousness with the 
mannerisms, their irritability with the impulsiveness, their 
good conduct with the automatic obedience of dementia 
praecox. 

On the grounds alleged the conclusion seems to me justi- 
fied that the psychic abnormalities which precede the real 
onset of dementia praicox already represent in part at least 
the action of the cause of the disease, even if they can be 
traced back into the first years of the patient's life. The 
commencement of the malady would be, if this view should 
be confirmed, moved back into childhood for a considerable 
number of the patients ; we should have to assume a longer 
or shorter preparatory stage, in which without noticeable 
progress, but already in indications the disease develops 
certain results such as we find again most strongly marked 
at the height of its development and in the terminal stages. 
This interpretation finds essential support, as appears to me, 
in the dementia prajcox of children and in engrafted hebe- 
phrenia. It has indeed here also been thought that it was 
a case of chance coincidence with other kinds of brain disease 
which only favoured the development of dementia pra_'Cox. 
But engrafted hebephrenia is on the one hand too frequent 



FREQUENCY AND CAUSES 239 

for the explanation to have much probability in itself, and 
on the other hand the weak-mindedness, which is its founda- 
tion, bears also most unmistakably the features of a hebe- 
phrenic terminal state, and the fresh attack very often assumes 
the features of a simple exacerbation of the already existing 
disorders. As in addition the appearance of dementia 
precox in early childhood is certain, there is no satisfac- 
tory reason according to my view to assume in engrafted 
hebephrenia an association of morbid processes of a totally 
different kind. 

The frequency of defective or poor endowment will from 
this standpoint, so far as it is characteristic of dementia 
praecox, be capable of being regarded at least partly as an 
expression of engrafted hebephrenia, modified to a certain 
extent, as the first still indefinite action of the same morbid 
process which later causes dementia praecox. More difficult 
to explain remains the fact which, as it seems, is also fairly 
certain, that a number of our patients exhibit strikingly good 
endowment. Here it would be necessary first to investigate 
how far it is a question of purely scholastic endowment of 
those scholars who with a good memory attain by good 
conduct, conscientiousness and indefatigable diligence to 
being " always the first in every class." Thus I remember a 
scholar, who with all the symptoms of a hebephrenic disposi- 
tion, shy, lachrymose, childish, wholly unboylike conduct and 
an ineradicable tendency to biting his nails, up to the highest 
class occupied the position of a prominent shining light in 
the school in consequence of his exemplai:y diligence, which 
nothing turned aside. But further, as degeneration certainly 
plays a part in the development of dementia praecox, the 
experience must be pointed out that on its soil not infre- 
quently distinguished, though mostly one-sided, endowment 
is present. As dementia praecox often encroaches later and 
in lesser degree on mental capabilities, and especially on 
memory, than on emotional life and volition, the former 
might in certain circumstances still stand on a higher level, 
while in the domain of the latter already distinct disorders 
have developed. 

If we regard certain predispositions which are frequent in 
the previous history of dementia praecox as the first slight 
beginnings of it, the question arises further, whether those 
peculiarities are to be interpreted always in this sense, and 
especially, whether the onset of dementia praicox must always 
follow them. The first question would only then be capable 
of an answer, if the last must be answered in the affirmative. 
But of that there can obviously be no dubiety. There are 



240 DEMENTIA PRECOX 

without doubt innumerable people who bear throughout their 
lives features such as we have formerly described without 
ever falling ill mentally. From that it must be concluded 
either that other kinds of inherited or acquired injuries could 
also exercise similar effects on the psychic life, or that in such 
cases the existing gerhi of dementia pra^cox has not attained 
to further development. The possibility of such an inter- 
pretation will not be capable of dispute in so. far as we see 
very slightly defective states as residuum of an attack of 
dementia pra^cox, which has been passed through, persisting 
often enough for decades, to the end of life without further 
progress. It would, therefore, be quite conceivable that 
certain abnormal personalities with the peculiarities men- 
tioned were to be regarded as the product of an attack of 
dementia praecox which had been passed through in earliest 
childhood and then reached the close. Bleuler is inclined to 
stretch the limits of such a " latent schizophrenia " to an 
extraordinary extent, and to interpret all possible psychopathic 
personalities in this sense. How far that is justified in fact 
can scarcely be decided at present. As even marked clinical 
symptoms do not always allow the conclusion to be made 
with certainty that the definite morbid process exists, we 
shall probably only quite exceptionally find the personal 
qualities characteristic enough to discover in them the 
infallible traces of an attack of dementia praecox which has 
been suppressed in its origin. 

External Causes. — About the part which external causes 
might play in the. development of dementia precox there is 
little to report. That mental over-exertion, which Kahlbaum 
suggested, and which is also held responsible in part by Deny 
and Roy, cannot be seriously taken into account, is already 
proved by the extension of the disease in the country 
population and among the Malays, Tamils, Chinese, peoples 
growing up in the simplest conditions of life. 

The view expressed by Vigouroux and Naudascher and 
supported also by Bleuler, that infections in the years of 
development might have a causal significance, cannot in its 
indefiniteness be either proved or disproved. The unmistak- 
able importance of the predisposition points, however, to the 
fact that infectious causes can scarcely be the decisive factor ; 
moreover other complicated factors must be assumed to 
explain the after-effects of such causes continuing for decades. 
At the same time in about lo to 1 1 per cent, of my 
patients at Heidelberg severe acute diseases had preceded 
the malady, most frequently typhoid or scarlet fever. 
Sometimes the picture of dementia prajcox developed abruptly 



FREQUENCY AND CAUSES 241 

during the bodily disease, so that at first an infectious 
insanity was thought of; as a rule, however, many years had 
passed before the appearance of the psychic disorder, so that 
there could be no question of direct connection. Now and 
then it was stated that since the bodily illness a certain 
change had already been noticed in the patient, greater 
irritability, a lowering of mental capability, a marked liability 
to fatigue. We shall regard with great doubt the statements 
of Bruce, who considers a short streptococcus the exciting 
cause of the disease, and was able by its means to produce 
" mental dulness" in rabbits. 

Just as little shall we be able to reconcile ourselves with 
the view represented by Steiner and Potzl that acquired 
syphilis could in certain circumstances bring the disease to 
an outbreak. It cannot be disputed that recent syphilis is 
often found in our patients, but that is not to be wondered 
at, as it has mostly to do with young people in the third 
decade, who are in part very much excited sexually and 
very much inclined to excesses. In isolated cases there was 
a report of inflammation of the brain in childhood, not 
altogether infrequently also of head-injuries}- which, however, 
are in any case so frequent, that they can only quite excep- 
tionally be made use of for establishing a cause. Also in 
brain diseases, especially tumours, " catatonic " morbid 
results are occ^isionally observed ; but we cannot doubt 
but that in such cases apart from chance coincidences the 
resemblances are purely external. The misuse of alcohijl 
appears to have no significance for the origin of dementia 
praecox. Though 15 to 16 per cent, of the men observed 
by myself had drunk heavily, as a rule it is a case of 
debauches which are caused by the morbid instability and 
irregular conduct of life of the patients. 

The fact already touched on is striking, that the outbreak 
of dementia praecox frequently takes place m prison. Among 
600 men about 6 per cent, had fallen ill in detention, in jail 
or in the convict-prison ; to these were added 8 per cent, of 
vagrants of whom likewise a considerable number had shown 
the first symptoms of the disorder in the workhouse. It is 
suggestive of the possibility that the emotional influences 
of the loss of freedom, the monotonous food, the limitation 
of movement, the being shut up from air and light, the 
facilitation of onanistic tendencies may be productive of 
disease. In more exadt investigation, however, it can be 
shown for a considerable number of the cases that probably 
already a long time previously changes of the personality 

^ V. Muralt, AUgem. Zeitschr. f. Psych. Ivii. 457. 

Q 



242 DEMENTIA PRECOX 

in the sense of dementia pntcox had taken place, which then 
made the patient a habitual criminal and vagrant. It is a 
remarkable fact that by preference paranoid forms develop 
on prepared soil through the influence of the loss of freedom, 
so that these, therefore, at least give a characteristic colouring 
to the morbid picture. Whether beyond this in individual 
cases the loss of freedom can gain real causal significance 
for dementia prrecox has become doubtful to me. 

Among 386 women there were 3 per cent, prostitutes. 
Once I saw two sisters fall ill almost at the same time who 
were both prostitutes ; a respectable young woman, already 
mentioned formerly, gave birth to three illegitimate children 
after recovery from a state of severe catatonic excitement. 
A woman fell ill while in custody, and became demented 
after she had prostituted herself in an incredible way, being 
urged to do so by her husband, he being present hidden in 
a cupboard. That probably the immorality in all such cases 
is the consequence and not the cause of dementia praecox 
scarcely requires more proof - 

We stand perhaps on a somewhat firmer foundation in 
the consideration of the relations between dementia praicox 
and the work of reproduction. Apart from the fact, that 
disorders of menstruation are frequent and, moreover, 
exacerbations of the morbid process are often observed 
during the menses, dementia praicox begins in a considerable 
number of cases during pregnancy, in childbed or after a 
miscarriage, sometimes also first in the period of lactation. 
In Heidelberg I saw nearly a fourth of the catatonic cases in 
women develop in connection with the work of reproduction, 
while of the hebephrenic cases not even in a tenth could such a 
connection be recognized. Once the four attacks, in which 
the disease ran its course, were each connected with a birth, 
till the last brought the final dementia. In another case the 
disease began likewise in childbed and after a remission of 
considerable duration ended with the occurrence of a fresh 
pregnancy in a severe relapse. As, however, the attacks of 
manic-depressive insanity also are readily connected with the 
changes caused by the work of reproduction, it must remain 
for the present undecided how far here it has to do with 
closer causal connections. The apparent increase of the 
attacks in the climacteric also has to be remembered, which 
would likewise correspond to the observations in manic- 
depressive insanity. 

Sexual Life. — Meantime the experiences touched on give 
us the occasion to examine somewhat more closely the 
behaviour of the- sexual processes in our patients. Here 



FREQUENCY AND CAUSES 243 

must be first pointed out what in the clinical descriptions 
must ever again be emphasized, that in our patients very 
frequently a lively sexual excitement exists, which makes 
itself known in regardless onanism, debauches, and tormenting 
sexual ideas of influence. Especially of male patients one 
learns with striking frequency that for many years they have 
constantly masturbated. Formerly, therefore certain morbid 
pictures belonging to hebephrenia were simply described as 
the " insanity of masturbation " ; perhaps also part of the 
widespread ideas about the terrible consequences of onanism 
is connected with such experiences. Lastly, it is worthy of 
mention that often the outbreak of dementia praecox is 
brought into causal connection with the abandonment or 
the failure of a plan of marriage. 

The observations quoted, which appear to point to rela- 
tions between dementia praecox and sexual life, have had 
much attention paid to them. Tschisch has come to the 
view that suppression or defective development of sexual 
activity is to be regarded as the cause of dementia praecox, 
and Lomer ascribes the cause to disorders of the internal 
secretion of the sexual glands. I also have expressed the 
view that possibly there might exist some or other more or 
less distant connection between dementia praecox and the 
processes of the sexual organs. It must meantime be empha- 
sized that convincing proofs for such assumptions are not by 
any means forthcoming. Increase of sexual excitement is 
found in all possible forms of insanity. Onanism meets us 
also frequently enough in simple psychopathies, and it might 
be encouraged in our patients by their shy reserve which often 
makes sexual approach impossible for them. The failure of 
plans of marriage is probably with more correctness to be 
regarded as consequence and not as cause of the disease. 
But lastly the considerations brought forward above, which 
point to a more frequent reaching back of the malady into 
childhood, take away part of the significance of its relations 
to sexual development, a significance which might be attached 
to these relations, if the quite similar behaviour of manic- 
depressive insanity is not taken into consideration. 

In any case we have to think of those connections, just as 
of those with pregnancy, childbed and climacteric as very 
common. One could perhaps imagine as connecting links, 
disorders in the bodily economies, as they accompany the 
great changes of life and in certain circumstances draw after 
them far-reaching consequences. Our attention has been 
drawn to these circumstances mostly by the better under- 
standing of the disorders of the thyroid gland, which likewise 



244 DEMExNTIA PRECOX 

exhibit certain relations to menstruation, pregnancy and 
climacteric. The occasional appearance of increase and 
decrease of the th)'roid, remarkable thickening of the skin, 
facial phenomena, acceleration or retardation of the pulse, 
tetanoid seizures, brings immediately to remembrance the 
phenomena observed in diseases of the thyroid gland ; on the 
other hand, according to lilum's descriptions, the disorders of 
the psychic life and of movement in dogs without a thyroid 
gland present a certain similarity to the behaviour of cata- 
tonic patients, Lundborg has therefore brought dementia 
praecox into relationship with myoclonia, myotonia and 
tetany, and has regarded as its foundation changes in the 
thyroid and parathyroids. 

Auto-intoxication. — At present it is obviously premature 
to form any opinion at all about the possibilities which might 
perhaps come into consideration for the explanation of the 
points of agreement indicated ; for that all serviceable founda- 
tions are still lacking. Nevertheless, the general statement 
may perhaps with all reserve be made, that a series of facts 
in dementia praecox up to a certain degree makes probable 
the existence of an auto-intoxication in consequence of a 
disorder of metabolism. Many investigators have found even 
the morbid anatomy similar to that of chronic iatoxication. 
Further Ajello believes that he is able to connect the changes 
brought forward by him in the behaviour of the muscles 
with the action of a toxin such as might perhaps correspond 
to veratrin ; also the frequency of idiopathic muscular swell- 
ings, heightened mechanical excitability of muscles and 
nerves, the increase of the tendon reflexes could be inter- 
preted in the same sense. Further evidence could perhaps 
be found in the statements, certainly still in need of more 
exact examination, about blood changes and metabolic dis- 
orders. Tomaschny has also interpreted the frequency of 
headache in the same sense. If we then still take into 
consideration the occurrence of o.steomalacia in dementia 
praicox emphasized by Barbo and Haberkandt, and lastly 
the above-mentioned relations to the work of reproduction, 
the indications appearing here and there of thyroid symptoms, 
the great fluctuations of the body-weight, with shapeless 
adiposity on the one hand, and the most extreme emaciation 
on the other, the occasional great fall of temperature, the 
epileptiform seizures, and the cases of sudden death, the 
conclusion is on the whole justified, that according to the 
present position of our knowledge the assumption of an auto- 
intoxication, which sometimes develops insidiously, some- 
times sets in violently, has for itself the greatest probability. 



FREQUENCY AND CAUSES 245 

About the source and kind of the toxin circulating in the 
body, we can certainly at present give just as little account 
as in the metasyphilitic or metalcoholic diseases which in 
their causes are already much better explained. 

Against this view it must be said that those observations 
appear at first to give evidence which point to a causal 
importance of the inherited or at least congenital pre- 
disposition. The view has often been brought forward, that 
hebephrenic dementia signifies nothing else than the gradual 
failure of an inadequate constitution. Like a tree whose 
roots find no more nourishment in the soil at their disposal, 
so the mental powers are said to disappear as soon as the 
insufficient dowry no longer allows a further unfolding. Pick 
speaks of a " failure of the vital capacity of the brain," of a 
" disproportion between efficiency and work." So enticing as 
this interpretation appears to be at the first glance, especially 
for the insidiously progressive inadequacy of dementia 
simplex and the forms similar to it, just as little nevertheless 
can it stand more exact examination. Already there is 
difficulty in understanding why the development of the 
patients without recognizable external cause should not only 
stop short all at once, but should directly end in profound 
psychic decline. To that must be added that the change, 
though it usually appears after all sorts of premonitory 
symptoms, still not infrequently occurs rather suddenly, that 
then again improvement lasting for years, indeed more or 
less complete recoveries, may occur after very severe morbid 
phenomena, all of these being circumstances which can 
scarcely be explained from the standpoint described. But in 
any case the fact is decisive, that the morbid anatomy has 
disclosed not simple inadequacy of the nervous constitution, 
but destructive morbid processes, as the background of the 
clinical picture. 

But neither from the clinical standpoint is there any 
ground for regarding dementia prjecox as the direct 
expression of a particularly severe degeneration. The part, 
which must be allocated here to the familial disposition, is 
rather smaller than in the pronounced forms of the insanity 
of degeneration, in manic-depressive attacks, in hysteria, and 
in psychopathy. Nevertheless we invariably meet there not 
the tendency to dementia, but rather morbid states filling the 
whole life uniformly or in periodic return without rapid 
progress. By these considerations dementia praecox comes 
nearer to epilepsy ; in it also, besides the undeniable import- 
ance of the inherited, or early acquired, constitution, we have 
cause to assume the development of definite, destructive 



246 DEMENTIA PR/ECOX 

morbid processes progressing either somewhat slowly or 
rather rapidly, which sometimes reach back into childhood, 
sometimes begin, or at least experience an exacerbation, 
about the time of sexual maturitj'. There also we come 
across facts which make the existence of disorders of 
metabolism in high degree probable ; epilepsy also is a very 
ancient disease and spread over the whole world. If one will, 
one may to the further understanding of the relations between 
constitution and disease bring into the discussion certain 
frequent disorders of metabolism with purely bodily abnor- 
malities, diabetes, gout, chlorosis, the occurrence of which is 
undoubtedly essentially favoured by inborn peculiarity. 

Freudian Complexes. — The adherents of F^reud's psycho- 
logy of complexes have gone their own way in the view 
which they take of dementia precox, as in many other 
clinical questions. Bleuler and Jung^ have first brought 
forward the opinion, that " complexes," groups of ideas 
strongly emphasized by emotion, are to be regarded as the 
causes of the morbid phenomena or at least of their appear- 
ance, complexes which here on morbid soil can give rise 
to specially momentous effects. They are said to exercise 
a far-reaching influence on thought and action and, according 
to Jung's expression, are able to rob the ego of light and 
air, as cancer takes the vital power from the body. In 
support of these assertions the experience is brought forward, 
that psychic causes frequently bring about improvement or 
aggravation in the state of the patients, and that many 
patients for a considerable time give utterance to ideas 
which are in connection with events of life emphasized by 
emotion. The former statement is in general correct and 
indeed self-evident, but is subject in detail to very many 
exceptions. If the latter statement were not true, here also, 
as in the most varied mental disorders of a different kind, 
it would certainly be wonderful. But I think from an 
experience sufficient for this question that I may conclude 
that it is far more rare than might be expected according 
to general psychological laws, or than we observe it to be in 
many other forms of insanit)-. What has bewildered me 
ever afresh innumerable times, was just the complete failure 
of the most natural complexes emphasized by emotion of 
healthy life. One may here certainly find the assumption 
helpful, that it is a case of suppressed and transformed ideas, 
of " masks," the real meaning of which can only be guessed 
by an interpretation, dependent on the fine feeling of the 

' Jung, L'ber die I'sychologie der Dementia pnvcox. 1907 ; Isserlin, 
Centralhl. f. Nervenheilk. u. I'sychiatrie. 1907, 329. 



FREQUENCY AND CAUSES 247 

observer, of association experiments and dreams, a proceed- 
ing which, judging by the examples forthcoming, has little 
attraction for me. But if by complexes nothing else is 
meant than delusions, in which the fears and wishes of the 
patients are reflected, that would be only a new and, as it 
appears to me, a not exactly desirable expression for an old 
thing. Its danger lies in the psychological views from which 
it proceeds. The idea of independent, parasitic psychic 
neoplasms, which on the one hand are completely withdrawn 
from the influence of the ego, but on the other hand are able 
wholly to transform and almost annihilate it, would overthrow 
such a number of everyday and thoroughly ascertained 
psychological experiences, that its substantiation must in 
any case be supported by quite other means of proof than 
has hitherto been the case. 

The opinion, that a large part of the clinical morbid 
picture can be explained by the effect of complexes, has then 
further led to the differentiation of primary and secondary 
symptoms. Only the former are said to represent the 
immediate expression of the destructive morbid process, 
while the latter proceed from the reaction to the influences of 
the surroundings and to the morbid efforts of the patients 
themselves. Thus according to Riklin negativism is said to 
depend on inhibitions by the action of complexes ; also the 
mistaking of persons, delusions, nonsensical answers, persever- 
ation, catalepsy, are connected with complexes, which 
furthermore hinder suitable adaptation to surroundings. All 
those expressions of morbidity are said to be just as 
comprehensible psychologically under the now existing 
hypotheses created by the disease as, according to Freud's 
explanations, dreams are, as soon as one has learned to 
interpret their intricate and extremely arbitrary symbolism. 
Jung even gave utterance to the sentence : " If we let an 
individual who is dreaming go about and act as if he were 
awake, we have the clinical picture of dementia praecox." 
Even though it were admitted that in the domain of thought 
and of speech-expression similarities exist between dreaming 
and dementia praecox, that statement is for the rest so 
evidently untenable, that a refutation appears the more 
superfluous as every proof at all acceptable is lacking. 

The separation of the morbid phenomena into primary 
and secondary I consider purely artificial. It certainly 
cannot be disputed that in our patients some domains of the 
psychic life are less injured than others and that many of 
their trains of thought, utterances and actions would be more 
comprehensible to us, if we knew their hypotheses, but the 



248 DEMENTIA PR.«COX 

wheelwork of our soul is so compactly fitted each part to the 
other, and the anatomical morbid process is moreover so 
widespread, that a division according to direct or indirect 
causation of the morbid phenomena appears to me on this 
account to be quite impossible. In any case the attempts, 
which up to now have been made in this direction, are not at 
all convincing. 

The distinction made by Bleuler o{ fundauiental disorders 
and accompanying phenomena of the disease is to be judged 
essentially otherwise. The former constitute the real 
characteristic of the clinical state and can be demonstrated 
in each individual case more or less distinctly ; the latter 
may be present, but may also be absent ; they are not caused 
by the character of the morbid process but by circumstances 
which are in loose connection with it. Those must therefore 
be regarded as fundamental disorders, which meet us in the 
picture of dementia simplex and in the terminal state called 
simple weak-mindedness, while all the remaining morbid 
symptoms represent obviously not necessary, though in part 
very common, accompanying phenomena of the disease. 
From this point of view the weakening of judgment, of 
mental activity and of creative ability, the dulling of 
emotional interest and the loss of energy, lastly, the loosening of 
the inner unity of the psychic life would have to be reckoned 
among the fundamental disorders of dementia prsecox, while 
all the remaining morbid symptoms, especially hallucinations 
and delusions, but also the states of excitement, depression 
and stupor, further the manifold disorders of volition, 
negativism, automatic obedience, stereotypy, mannerisms, 
impulsive actions, would be regarded more as secondary 
accompanying phenomena. Bleuler reckons "ambivalence " 
and " autism " also among the fundamental disorders, not, 
however, as appears to me, altogether with right, as there are 
terminal states in dementia prsecox, in which these abnor- 
malities are lacking, while the above-mentioned fundamental 
disorders are present. 

By what circumstances the appearance in the clinical 
picture of the secondary phenomena mentioned is caused, is 
at present unknown. Paralysis will be called to mind here, 
where likewise, the simple, characteristic dementia, which is 
the rule in the childish paralytic, may be elaborated by 
delusions, states of excitement, ill - humour and so on. 
Differences in the course and in the local extension of the 
morbid process might not be without significance. The 
forms which develop insidiously usually bear the stamp in 
paralysis, as in dementia praecox, of a simple, progressive 



FREQUENCY AND CAUSES 249 

weak-mindedness, and those, which have a violent onset, that 
of states of excitement and confusion with vivid delusions. 
Lastly, for the form of the clinical picture the circumstance 
might not be without significance, that according to the 
development of the psychic personality the morbid process 
must injure sometimes these, sometimes those faculties of the 
brain in a more striking way. I do not think here of the 
effect of complexes which have been acquired by chance 
and have become psychic parasites, but of the very varied 
consequences, which a change in the brain must have 
according to the particular direction, in which the faculties of 
the individual complicated brain machine and in especial of 
the injured parts have been fashioned by life. Thus the 
rarity observed by myself of hallucinations of hearing in 
the Javanese patients might be explained by the slighter 
significance which speech ideas have there for thought ; thus 
we have seen that with progressive development and rigidity 
of the psychic personality the delusions usually become more 
connected and more systematized. It would also well be 
conceivable that for the form of the peculiar catatonic 
disorders of volition besides the kind and extent of the 
morbid changes, the special volitional constitution might be 
of importance ; I found it striking that the disorders mentioned 
seemed to be less pronounced in the Javanese patients than 
with us. 

While Bleuler ascribes significance to complexes and in 
general to psychological influences only for the form of the 
clinical condition, Jung claims them in certain circumstances 
also as a real cause of the disease. The complex emphasized 
by affect is thus said to be able to act as the starting-point 
of the disease in a way similar to that of a trauma or an 
infection. That might be conceded in so far as the origin 
of an attack of dementia praecox by trauma or infection is 
just as unproved as by complexes. But Jung gets a con- 
nection here with the theory of intoxication by pointing 
out the possibility of the emotion being able to produce a 
kind of toxin, as it otherwise might well arise of itself and 
might cause the disease. Surely then it would not be under- 
stood why the manic-depressive patients with their violent 
emotions do not produce the destructive toxins which lead 
to dementia in the greatest quantity ! 

Abraham has taken the Freudian doctrines into the service 
of dementia praicox more on the sexual side. For him the 
malady signifies the "auto-erotic" disposition, existing from 
youth up, the incapacity for objective love, which produces 
in its own time the withdrawal from the surroundings, 



250 DEMENTIA PRyECOX 

especially the aversion to the parents formerly* involved in 
erotic relations, as well as the ideas of persecution, further 
the tendency to onanism and, by the transference of sexual 
overestimation to the patient's self, megalomania. The 
persecutors are frequently people the patient has formerly 
loved ; the hallucinations always concern the complex. 
Another series of similar " analyses " of the mental state 
in dementia praicox has come from the Zurich School. They 
all run in the direction of gaining an understanding of the 
deeper sense which is hidden behind the " mask " of the 
confused talk and incomprehensible actions of the patients. 
" Freud and Jung have shown that the system of delusions 
of the patients is not in the least nonsensical, but follows 
the same laws as perhaps a dream, which always discloses 
itself as a sensual elaboration of a complex," is what is said. 
But the complexes are as good as without exception sexual. 

Here we meet everywhere the characteristic fundamental 
■features of the Freudian trend of investigation, the repre- 
sentation of arbitrary assumptions and conjectures as assured 
facts, which are used without hesitation for the building up 
of always new castles in the air ever towering higher, and 
the tendency to generalization beyond measure from single 
observations. I must frankly confess that with the best 
will I am not able to follow the trains of thought of this 
" metapsychiatry," which like a complex sucks up the sober 
method of clinical observation. As I am accustomed to 
walk on the sure foundation of direct experience, my 
Philistine conscience of natural science stumbles at every 
step on objections, considerations and doubts, over which 
the lightly soaring power of imagination of Freud's disciples 
carries them without difficulty. I also hold the view that 
many speeches and actions of our patients are not so non- 
sensical as they appear to us and that sexual emotions 
certainly play a considerable part in them. But as I only 
succeed very exceptionally in explaining rriy own dreams 
to a certain extent, although the preliminary conditions are 
certainly as favourable for that as possible, I must not only 
say explicitly that the statement, that a dream " always 
discloses itself as a sensuous elaboration of a complex," is 
wholly imaginary, but I am also unable to pluck up courage 
to give any credence to the disclosures which are yielded 
by the "analysis" of the processes of consciousness of our 
patients which are infinitely more difficult to understand, 
Certainly anyone who can decide to regard the utterances 
of the patients sometimes literally, sometimes as the 
expression of the contrary, sometimes again as " symbols " 



FREQUENCY AND CAUSES 251 

of any other ideas whatever, who in all these expulsions, 
displacements, concealments, finds his way with confidence, 
will not find it too difficult in the end to discover in a fable 
ofGellert a background of secret incestuous thoughts, jealous, 
masochistic, sadistic or homosexual emotions. 



• CHAPTER X. 
DELIMITATION. 

Whether dementia praccox in the extent here delimited 
represents one uniform disease^ cannot be decided at present 
with certainty. In any case we shall no longer need to 
refute in detail the objection formerly brought from different 
sides against the establishment of the morbid form, that it 
was a case of unjustified grouping of uncured psychoses of 
very different kinds, of melancholia, mania, acute and chronic 
confusion, derangement. Clinical experience has demon- 
strated innumerable times that it is possible from the 
conception of the pathology of dementia precox to foretell 
with great probability the further course and the issue of a 
case belonging to the group ; but in saying that, the proof is 
furnished that our picture of dementia praecox is in the main 
agreeable to natural laws. Nevertheless, it is certainly 
possible that its borders are drawn at present in many 
directions too narrow, in others perhaps too wide. 

Paranoid Forms. — The most criticism has always been 
directed against the inclusion of the paranoid forms in 
dementia precox. It cannot be denied that the pictures of 
paranoid states at first sight do not have the slightest 
resemblance to those of catatonic stupor, of excitement or 
of dementia simplex. Meantime the diversity among one 
another of the pictures described, as also all similar experi- 
ences in other diseases, such as in paralysis, in cerebral 
syphilis, in manic-depressive insanity, point to the fact that 
it is very hazardous to draw conclusions from the clinical 
states alone as to whether they belong to the same or 
to different forms of disease. This question can only be 
decided by the whole course of the malady, and the 
appearance, gradually becoming always more distinct, of 
those morbid symptoms which are essential to the disease as 
opposed to the more secondary, though often much more 
striking, accompanying phenomena. 

If we apply these principles to the case before us, the 
result is that at least some of the attacks beginning in 
paranoid form, as before described, issue in quite the same 



DELIMITATION 253 

terminal states as the remaining forms of dementia praecox. 
The delusions, which originally completely dominated the 
morbid picture for years, may vanish leaving scarcely a trace, 
may be corrected by the patient, denied or forgotten, while 
a simple hebephrenic weak-mindedness remains. In other 
cases again there are, interpolated in a paranoid morbid 
course, states which bear unmistakably the stamp of dementia 
praecox, silly excitement with mannerisms and stereotypies 
or negativistic stupor. Fuchs has described a case in which 
between two such acute attacks for more than ten years a 
purely paranoid state was present. Lastly, it must be 
pointed out that delusions and hallucinations of quite the 
same kind, as we see them in paranoid cases, occur also in 
most of the remaining forms of dementia praecox, certainly 
here in connection with a series of other morbid symptoms. 
The changing composition of the morbid pictures in a given 
group of phenomena with sometimes weaker, sometimes 
stronger characterization of single features is, however, quite 
familiar to us from the most different clinical groups of 
forms ; we shall therefore not lay too much stress on the 
occasional absence or more striking appearance of single 
characteristics for the clinical judgment of the states, and all 
the less if we see their composition repeatedly change in one 
and the same case of disease. 

In any case we may, as I think, regard it as certain that 
paranoid states may appear in the course of dementia 
prsecox. The question is much more difficult to answer, 
how wide the circle of paranoid cases must be drawn, which 
we are justified in regarding as expressions of that disease. 
Although it appears to me to be impossible at present to 
arrive at a definite conclusion on this point, nevertheless I 
have thought, with reference to the doubt which I expressed 
before, that I should attempt to make a narrower delimita- 
tion. Accordingly I have for the present separated from 
dementia praecox a part of Magnan's " delire chronique " and 
what was formerly called dementia paranoides, now named 
" dementia phantastica." On the other hand I have still 
included in dementia praecox those paranoid forms which 
pass with comparative rapidity into marked psychic decline 
and in which, besides delusions and hallucinations, those dis- 
orders of emotional life and volitional activity can be demon- 
strated in more or less distinct form, which meet us so 
invariably in the disease named. It is proved, as far as I 
can see, to be wholly impossible to delimit them sharply 
in any way from the first-mentioned paranoid form. Certainly 
the grouping which is now attempted is not final ; but at 



254 DEMENTIA PRECOX 

present we still wholly lack the hypotheses for a satisfactory 
solution of the task here before us. 

Catatonia. — For several other groups of cases also the 
separation from dementia prajcox has been recommended. 
Tschisch has emphasized that catatonia and dementia 
praecox are fundamentally different from each other, and 
Morselli^ also has come to the conclusion, that catatonia 
deserves a place to itself; it is curable, and is caused by 
infections. According to my observations I must consider 
these views erroneous or at least wholly unproven. Even 
though after infectious diseases morbid pictures similar to 
catatonia come under observation, they can still not be 
grouped together with the very great majority of cases in 
which such causation can be easily established. Whether 
catatonic cases may be cured under certain circumstances, 
was formerly investigated in detail ; as a rule, however, they 
are not cured. Catatonic states may further appear suddenly 
in each period of dementia praicox, sometimes only after 
a decade. Then we observe after catatonias exactly the 
same terminal states as in the remaining forms of dementia 
praicox ; but lastly, the " catatonic " symptoms may be 
present in the morbid picture in all possible grades and 
groupings. I see, therefore, no possibility of attaining with 
their help to a delimitation of an independent clinical form. 

Meeus has proposed to delimit a hebephrenic-catatonic 
group from the paranoid forms and from dementia simplex. 
I think, however, that we need not recognize this as a 
separate disease. It represents, strictly speaking, the previous 
history of numerous cases of dementia praecox, in which a 
fuller development of the clinical picture takes place later. 
If one will, one may place the slighter cases alongside the 
^' formes frustes," as they are described by the French in 
morbid pictures of another kind, the forms with poorly 
developed disorders, while the more severe would be com- 
pared with perhaps the simply demented paralysis. As 
numerous cases, beginning first as dementia simplex, later 
follow the ordinary course of dementia pra;cox, we have to do, 
as Diem also has already emphasized, with indefinite bound- 
aries. Nor can I make up my mind to make a special place, 
as Vogt proposes, for dementia infantilis. It will have to be 
admitted that the conception of the disease has hitherto been 
insufficiently elucidated, and that therefore among the so- 
called cases all sorts of component parts of various kinds 
may be found. Nevertheless the picture described appears 
to me to correspond so completely with the dementia praicox 
' MorKlli, Rivista di freniatria sperimentale xxsiv. 3. 



DELIMITATION 255 

of adults, that we may without hesitation ascribe to it the 
majority of the cases with the proviso of the , rejection of 
extraneous admixtures, as the assumption of a dementia 
praecox in childhood can present no difficulty to us now. 

Psycho-reaction. — An extremely convenient solutionof all 
these questions of delimitation seemed to be offered by the 
" psycho-reaction " brought forward by Much and Holzmann. 
It was a question of the inhibition in the presence of the 
serum of certain mental patients of the lysis of human red 
blood corpuscles effected by cobra poison. As this inhibiting 
effect was said only to belong to the serum of patients with 
dementia praecox or manic-depressive insanity, it would have 
furnished us with a valuable aid for establishing whether 
definite morbid pictures belong to one of those two great 
forms, and therewith also to the distinguishing of independent 
groups. If meantime the fact that the psycho-reaction is 
common to two groups of forms, which certainly are not 
nearly related clinically, had not aroused very grave doubts 
as to its reliability, further investigation has given the result, 
that there can at present be no talk of a diagnostic peculiarity 
in that kind of reaction, but that it much rather sometimes 
■ appears, sometimes fails, in morbid states of the most various 
kinds, and also in healthy individuals, just as in the forms 
named. 

Clinical Experience. — We have therefore even yet to 
rely purely on the valuation of clinical experience. The 
result is, as it appears to "me, that we are with great proba- 
bility justified in connecting the great majority of the cases up 
to the present brought together under the name of dementia 
prcccox with the same morbid process, and therefore in re- 
garding it as a single form of disease. Everywhere the same 
fjindaniental disorders return again, the loss of inner unity in 
thinking, feeling, and acting, the dulling of higher emotions, 
the manifold and peculiar disorders of volition with the con- 
nected delusions of psychic constraint and influence, lastly 
the decay of the personality with comparatively slight 
damage to acquired knowledge and subordinate expertness. 
These features are certainly not all demonstrable with full 
cld'arness in each individual case. But still the general view 
over a great number of complete observations teaches that 
nowhere can a state be discovered which is not connected 
by imperceptible transitions with all the others. 

In any case the differences in the individual clinical cases, 

• as soon as their whole development is taken into account, 

seem to me to be not greater than possibly in paralysis. If 

one will, one may even in the appearance of simple demented, 



256 DEMENTIA PR.'ECOX 

expansive, depressive, stuporous, galloping, and stationary 
varieties of the course, with or without remissions, as also of 
juvenile cases of a peculiar form, recognize a certain general 
agreement in the principal clinical features of the two 
diseases. As the delimitation of paralysis is now assured, 
the objections drawn from the difference of the states to the 
view of dementia praecox as a unity would be thereby 
weakened. We certainly miss in paralysis the real paranoid 
forms, but instead we find them again in cerebral syphilis, 
the clinical forms of which have a still greater multiplicity to 
show. 

If we may, therefore, also regard the essential outlines of 
dementia pr?ecox as assured, one must reckon with the 
possibility, indeed the probability, that progressive knowledge 
will yet bring us all kinds of rectifications of the limits of the 
disease. The giving a place to the childish forms of the 
malady, which certainly requires further investigation, 
signifies material progress also with regard to our ^etiological 
views. Perhaps also the very desirable clearing up of the 
doctrine of the "late catatonias" will bring us a further 
increase of forms. On the other hand again perhaps some of 
the smaller groups will in course of time be got rid of; I 
think first of this possibility namely for the cases with 
confusion of speech and those with 2l periodic course. 

The hypothesis has also frequently been brought forward 
that a morbid process other than dementia may be the 
foundation of the apparently cured cases. I will not dispute 
this possibility. Partly it will certainly be a simple mistake 
in diagnosis mostly to the loss of manic-depressive insanity. 
But there might well be also other curable forms of disease of 
different kinds with phenomena like catatonia, which we at 
present are not yet in a position to distinguish from dementia 
praecox. Those cases with simple persistence of hallucina- 
tions without decay of the personality might also come under 
consideration. It must, however, be recognized that urgent 
reasons for the separation of the cases, which do not go on to 
dementia, are as yet absent. The assumption, that the 
morbid process of dementia precox, according to its severity 
and according to its extent, may not only produce phenome'na 
of loss of different kinds, but also sometimes issue in 
recovery, sometimes lead to more or less profound dementia, 
is in itself not improbable. Certainly we shall cherish the 
eager wish to become clear as soon as it is at all possible, as 
to which way it will take. 



CHAPTER XI. 
DIAGNOSIS. 

The diagnosis of individual cases of dementia praecox has 
to distinguish the manifold states from a whole series of 
diseases which outwardly are similar but which are totally 
different in their course and issue. Unfortunately there is in 
the domain of psychic disorders no single morbid symptom 
which is thoroughly characteristic of a definite malady. 
Much rather each single feature of the morbid state may in 
like, or at least very similar form, also make at a time the 
impression of an essentially different morbid process in 
which exactly the same areas are involved. On the other hand 
we may expect that the composition of the entire pictui-e made 
up of its various individual features, and especially also the 
changes which it undergoes in the course of the disease, could 
scarcely be produced in exactly the same way by diseases of 
a wholly different kind ; at this or at that point, sooner or 
later, deviations will be certain to appear, consideration of 
which makes possible for us the distinguishing of the morbid 
forms. It may in certain circumstances be very difficult, not 
only to judge correctly of the diagnostic significance of such 
deviations, but even to recognize their very existence. 

Catatonic Symptoms. — Special importance in the estab- 
lishing of dementia praicox has, not without justification, 
been attributed to the demonstration of the so - called 
" catatonic " morbid symptoms. Under this term must 
principally be understood the volitional disorders first 
described by Kahlbaum as accompanying phenomena of 
catatonia, automatic obedience, negativism, mannerisms, 
stereotypies, impulsive actions. As undeniable as it is, that 
all these disorders in no other disease come under observa- 
tion in such extent and multiplicity as in dementia praecox, 
just as little, however, may the appearance of one, or even 
of several, of these disorders be regarded as infallible proof 
of the presence of that malady. Certainly this restriction 
holds good in very different degree for the individual 
disorders. Automatic obedience, which represents only a 
sign of the surrender of the patient's own volition, is found 

R 



258 DEMENTIA PRECOX 

in a large series of morbid states of the most dififerent kinds, 
and possesses therefore only very slight diagnostic significance. 
Impulsive actions and stereotypies come under observation 
in severe brain diseases, specially in paralysis, in infectious 
psychoses, in senile dementia, in idiots, and can therefore 
likewise only be used with great caution for the establishing 
of dementia pra^cox. Much more characteristic are negativism 
and mannerisms, which scarcely accompany any other morbid 
process uniformly in a pronounced form throughout a long 
period. 

At this point meantime the consideration arises, that it is 
often uncommonly difficult to decide whether we really have 
to do with genuine catatonic morbid symptoms or not. 
Automatic obedience may be simulated by shyness ; impul- 
siveness of action by obscurity of motives in clouding of 
consciousness with inhibition of the movements of emotional 
expression ; stereotypy by uniformity of volitional actions, as 
that may be caused by the domination of definite, over- 
powering ideas or emotions. From genuine impulsive 
negativism there must be distinguished the surly, stubborn 
se>f-will of the paralytic and of. the senile dement, the 
playful reserve of the hysteric, the pertly repellent conduct 
of the manic, and from the senseless perversities in action 
and behaviour, as they occur in dementia pra^cox, the con- 
ceited affectation of the hysteric, as also the wantonly funny 
solemnity of the manic patient. Often it will onl)' be 
possible to find out these and other similar differences after 
considerable observation among changing conditions, after 
having made all sorts of experiments on the conduct of the 
patients under influences of various kinds; sometimes informa- 
tion is first got from observations in quite other domains 
about the correct interpretation of the phenomena. 

Psychopathic States. — If we now consider in order the 
diagnosis of dementia praicox from individual disea.ses of 
another kind,^ the question first comes before us, how far it 
may be confused with states produced by morbid predisposi- 
tion. That among psychopathic inferior personalities a 
group is possibly found which we may regard as undeveloped 
cases of dementia pra,xox, as " latent schizophrenia " accord- 
ing to Bleuler's terminology, was formerly mentioned. Occa- 
sionally there come into notice certain shy, whimsical, 
queer people, and then perhaps many irritable, unaccountable 
psychopathies with a tendency to distrust and overweening 

' ScViotl, .Monatsschr. f. Psychiatric u. Neurol, xvii. Erg.-Heft99; Wilmanns, 
Centralblalt f. Nervenhcilk. u. I'sychiatrie 1907, 569; Bornstein, Zeftschr. f. d. 
ges. Neurol, u Psychiatric v. 145. 



DIAGNOSIS 259 

self-conceit, who may at least with a certain probability be 
supposed to be suffering from dementia pra-cox. On the 
other hand we cannot well accept such an interpretation for 
the great mass of those morbid states the foundation of 
which is anxiety and want of self-confidence. If the conduct 
of life exhibits here ever so many peculiarities and apparent 
incomprehensibilities, their origin can yet invariably be 
traced back in one or another way to intelligible motives. 
Only a small group of childishly weak-minded, weak-willed 
personalities without initiative, with hypochondriacal failure 
of volition, seems to belong to the frontier territory of 
■dementia simplex. 

Not at all infrequently a commencing dementia preecox 
is looked on as simple nervousness, hypochondria or neuras- 
thenia and treated according})', and still more frequently 
regarded as moral depravity. The increasing failure in work 
is connected with exhaustion and over-exertion, perhaps also 
with the influence of some or other occurrence. Here above 
everything the decisive points for the diagnosis are the signs 
of psychic weakness, the want of judgment, the senselessness 
of the hypochondriacal complaints, the inaccessibility towards 
the reassuring statements of the physician, the emotional 
dulness and want of interest, the lack of improvement on 
relaxation from work, further, the more or less distinct 
manifestations of automatic obedience or of negativism. 
Hallucinations and sudden incomprehensible impulsive 
actions naturally are wholly in favour of dementia praicox. 

Numerous patients, who on account of moral incapacity 
either become habitual criminals, or fall into prostitution, or 
who, being incapable of earning a living, drift into a vagrant 
life, are for many years disciplined and punished, if the more 
striking symptoms of dementia precox are absent, till the 
appearance of more severe disorders, states of excitement and 
stupor, hallucinations of hearing, and delusions, makes clear 
the morbidity of their state. Here also the incoherence of 
thought and action and the peculiar dulness with which the 
patients let everything happen, may give hints to the expert 
for a correct decision. Of special importance is the proof, 
that in a certain period of life a change of the whole 
personality, a deterioration and a failing, has taken place ; 
still the forerunners of such an " acquired folic morale," as we 
have seen, go back even to childhood. Many patients fall 
into drinking habits and then the extraordinary rapidity is 
surprising with which they break adrift, carry out the 
most incomprehensible actions, and become completely 
demoralized. At the same time there exists also in 



26o DEMENTIA PR.4£COX 

sober moments a complete lack of understanding for the 
consequences of what has happened and dull indifference 
towarck them. 

Imbecility and Idiocy. — States of weakness, which are 
produced by dementia pr.xcox, may be regarded as imbecility 
or idioc)', especially when they have already arisen in child- 
hood, while otherwise the previous history will as a rule 
point to the peculiarity of the malady. Sometimes it is 
possible from the comparison of present performances with 
earlier school reports, essays, letters, to establish the fact of 
the mental falling off, and from that to conclude that the 
case is probably one of dementia pr^ecox. Where residua 
of the disease, which has been passed through, have been 
left behind, hallucinations of hearing, delusions, mannerisms, 
negativistic features, the decision will be easy. Simple 
rhythmical movements are, however, not of use for diagnosis, 
which may, as a symptom of very profound injury to the 
volitional mechanism, be produced by other morbid pro- 
cesses. If it is a case of simple weak-mindedness without 
specially characteristic disorders, the disproportion between 
knowledge and ability may often give effective points for 
decision. As by dementia pra'cox what is remembered is 
less injured than the ability to use it, we often still find 
surprising knowledge, while efificiency has suffered most 
severe losses. Imbeciles on the contrary can often manage 
fairly well in their daily tasks, even when their knowledge 
is of the very lowest degree. Correct recognition is very 
important especially in military service, as the profound 
incapacity of the hebephrenic is easily interpreted as laziness 
and obstinacy and then leads to discipline which may have 
as a consequence serious exacerbations of the state. Weak- 
mindedness which has existed from childhood without focal 
phenomena, which later experience an exacerbation, is as 
a rule to be regarded as engrafted hebephrenia, if epilepsy 
and cerebral syphilis can be excluded, the former by the 
absence of seizures, the latter by the negative result of the 
Wassermann reaction. In many cases the recognition of 
the condition is made essentially easier by the failure of the 
psychic pupillary reaction. 

Manic-depressive Insanity. — By far the most important 
point in diagnosis, but at the same time also the most 
difficult, is the distinguishing of dementia pra^cox from 
isolated attacks of manic-depressive insanity.^ As little as 
we can doubt that here we have to keep separate two morbid 

' Urstein, Die Dementia pnx'cox und ihre Stellung zum maiiisch-depressiven 
Irresein. 1909; Thomsen, AUgem. Zeitschr. f. Psychiatric, Ixiv. 631. 



DIAGNOSIS 261 

processes quite different in their character, and as simple 
as the delimitation is in the great majority of cases, Just as 
ihsufficient do our distinguishing characteristics yet appear 
in those cases in which we have before us a mingling of 
morbid symptoms of both psychoses. 

Opinions still differ widely as to whether here greater 
weight must be attributed to the catatonic or to the circular 
symptoms for the classification of the case. I consider indeed 
the putting of this question wrong, and am coming more 
and more to the view that one must on principle beware 
of attributing characteristic significance to a single morbid 
phenomenon. Not even states differing so widely from each 
other as manic, paralytic, and alcoholic excitement can be 
distinguished from each other with certainty on the ground 
of a single psychic characteristic. We must indeed also keep 
in mind that the causes of disease everywhere meet preformed 
mechanisms in our brain, whose independent morbid activity 
attains to expression in the clinical picture. All possible 
stimuli will, therefore, by their attack at the same point be 
able to call forth perhaps very similar psychic morbid 
phenomena. But what hardly ever is produced in quite 
the same way by morbid processes of different kinds, is, as 
already mentioned above, the total clinical picture, including 
development, course and issue. If, therefore, isolated morbid 
symptoms and in certain circumstances whole pictures of 
states cannot always be interpreted with certainty in the 
sense of a definite disease, a complete survey of the whole 
disease will then at least invariably lead to the goal, when 
our knowledge of the domain concerned already suffices for 
the needs of such a task. 

In the controversy about the significance of isolated 
morbid symptoms, however, it must further be kept in view, 
that their value is of very varied kind. Thus the frequently 
employed conception of " catatonic " phenomena ^ embraces a 
number of characteristics which are only in the smallest part 
specially peculiar to catatonia. Catalepsy, echophenomena, 
making faces, affected behaviour, speaking past the subject, 
speaking in artificial languages, rhythmic movements, peculiar 
gestures and attitudes, none of these by themselves alone 
justify, as with VVilmanns I must emphasize, the regarding of 
a case as catatonia. A more or less convincing proof is 
given by their accumulation and their connection with yet 
other disorders in themselves likewise not characteristic, as 
hallucinations of hearing, delusions of influence on will, 

1 Soutzo, Les symptomes catatoniques ; leur mecanisme et leur valeur 
clinique 1903. 



262 DEMENTIA PR^XOX 

repellent conduct, indifference towards the surroundings, 
lack of susceptibility to influence, absence of movements of 
defence, abrupt change from stupor to excitement and so ori. 
As already mentioned, genuine negativism, instinctive, purely 
passive resistance, seems to me to possess the relatively 
greatest significance as an isolated symptom. Here also, how- 
ever, a mistake ma\' be made, especially as it is sometimes 
impossible to be certain whether the resistance is instinctive 
or founded on imagination and emotional occurrences. The 
same difficulty meets us, moreover, in the remaining catatonic 
morbid symptoms. On this account they cannot always 
signify the same thing, because in the isolated case we know 
only the outward behaviour but not the inward origin. 

As it appears to me, the circular morbid symptoms can 
make just as little claim to inviolable diagnostic significance. 
In the first place that is true for the periodic and also for the 
circular course, which, even though perhaps with certain 
deviations, may occur in very similar way in dementia 
pr.necox. Manic pressure of activity, which in its slighter 
forms is so characteristic, often in great excitement nearly 
approaches the picture of catatonic raving mania ; the flight 
of ideas in similar circumstances becomes not infrequently a 
monotonous, persistent drivel. For the inhibition of will and 
thought the same may be said as for negativism ; it ma)' be 
impossible to distinguish them from the failure of mental 
activit)- and of volitional impulse, which is peculiar to 
dementia prjecox. Sometimes the patients are themselves 
able to give an account of the inner origin of their actions, 
which then may become of special importance .for the 
interpretation. Indubitably even that does not always allow 
of a certain judgment being made. At the commencement 
of a case of dementia precox, when the patients often feel 
very distinctly the gradual annihilation of their will, one 
hears from them frequently utterances quite similar to those 
of the manic-depressive patients, although they are in reality 
related to essentially different processes. 

The states of manic-depressive insanity therefore will not 
be, as I think, recognized from one isolated symptom, even 
though it may apparently be capable of only one interpreta- 
tion, but only from the whole clinical picture with cautious 
weighing of the relations which exist between the individual 
features. P'or the delimitation from dementia pra.'cox great 
weight must without doubt be laid on "intrapsychic ataxia," 
which was brought by Stransky especially into the fore- 
ground, that is on the want of inner logical arrangement of 
psychic events, which distingui.shes this di.sease. IJn- 



DIAGNOSIS 263 

fortunately it is not always easy to reco^jnize the existence 
of this disorder, as also in the mixed states of manic-depressive 
insanity ; owing to injuries of various kinds to nearly 
related functions and the interconnection of different states, 
pictures may temporarily arise which externally at least are 
similar. (Flight of ideas with inhibition of thought, exalted 
ideas with depressive mood and so on). 

From different sides the attempt has been made to use 
association experiment for the characterization of the two 
diseases discussed here. Isserlin draws .special attention to 
the fact that manic-depressive patients invariably exhibit a 
desire to try the exercise, even though they ma\- appear 
indifferent and impoverished in thought. In contrast to that 
there is observed in dementia praecox persistence of individual 
answers, sometimes through whole series of attempts, wholly 
nonsensical or manneristic associations, repellent conduct, 
abrupt change between very short and greatly prolonged 
periods. Bornstein also found frequent absence, repetitions, 
poverty of associations in dementia praicox in contrast to the 
tendency of the manic patients to* produce all possible 
associations and to spin the thread further ; the clang- 
associations which are frequent in the latter were almost 
ehtirely absent in the former. 

If we now look at the individual clinical states in the 
depressive forms, the early appearance of numerous hallucina- 
tions of hearing and of nonsensical delusions, in particular 
the idea of influence on will, makes dementia praecox pro- 
bable, especially if ordinary sense remains preserved. Hal- 
lucinations of hearing are in manic-depressive insanity much 
rarer and have generally a less definite stamp, so that the 
patients usually reproduce their content not in exact words 
but only in general expressions ; they very frequently refer 
them to their own thoughts as voices of conscience, and are 
very much disturbed by them, especially as the content is 
invariably in the closest relation to their depressive ideas. 
The train of thought of the patients is made difficult, and 
they become painfully aware of this. Wilmanns places 
extraordinary weight on this " intrapsychic inhibition," the 
" feeling of insufficiency," for the diagnosis of manic-depres- 
sive insanity, and considers it, just like the hypomanic mood, 
to be more characteristic than the " catatonic " phenomena in 
dementia praecox. On the other hand I have still doubts of 
all kinds. 

It is, however, correct, that the patients with dementia 
praecox, who likewise often complain of incapacity for 
thought, usually describe not so much the feeling of inward 



264 DEMENTIA PRyECOX 

inhibition as that of influence by external forces ; they 
cannot think what they will, and must think what they do 
not will, what is forced on them, while the manic-depressive 
patients cannot collect their thoughts and reduce them to 
order, or in certain circumstances, as when they have an 
inward flight of ideas, cannot retain them, but they only 
exceptionally feel themselves dominated by external influ- 
ences. Urstein thinks that the patients with dementia prse- 
cox only feel subjective inhibition, while the patients in the 
circular states of depression are inhibited subjectively and 
objectively. I cannot agree with either opinion. 

In general there is found in the manic-depressive patients 
more tendency to, and ability for, the obset~)ation of self, to 
painful dissection of their psychic state, in contrast to the 
indifference with which in dementia pr.tcox we so often see 
the patients regard the most deep-reaching disorders of their 
psychic life. In the latter even the most exciting delusions 
are produced with remarkably slight emotional participation, 
and as a rule also they do not induce in the patient any 
definite, intentional miction. It is striking in the highest 
degree that the patients are usually not at all disturbed by 
"the phenomenon, just as mysterious as it is weird, of hearing 
voices, apart from their content sometimes provocative, 
sometimes wholly trifling, and often for months do not utter 
the slightest complaint on that account, when they are not 
specially questioned on the subject. Generally it is only 
with difficulty that a glance is gained into the occurrences of 
their inner life, even when the patients are able to give 
utterance without difficulty to their thoughts ; they are 
taciturn, repellent, evade questions, give indefinite information 
that tells nothing. Neither do they take any share in what 
happens in their surroundings; they do not greet their 
relatives who visit them, they do not speak a word during 
the visit, but perhaps devour greedily everything that is 
brought to them. 

In contrast to that the signs of anguish or dejection are 
never absent in circular states of depre.ssion. It is true that 
the expression of the inward states may be limited to a con- 
siderable extent. Nevertheless the emotional susceptibility 
to influence is shown by stimulation of ideas emphasized by 
emotion, by letters, by visits, with considerable persuasion 
most unmistakably in the signs of tension or excitement, 
sometimes even in violent outbursts of feeling. By the 
occurrences in their surroundings the patients are much 
more strongly moved, relate them to themselves, fall into 
anxiety. While in dementia pracox the emotions are silent, 



DIAGNOSIS 265 

without the patients noticing the disorder, or being disturbed 
about it, the manic-depressive patients complain in despairing 
accents of the feeling of inward desolation and emptiness, 
of their inability to feel joy or sorrow, although in their 
conduct emotional reactions of great vivacity appear. 
Towards the physician likewise they are indeed often mono- 
syllabic, but do not make evasions ; they let themselves be 
stirred up by persuasion to further utterances, and they 
invariably bring forth their complaints with the signs of 
inward agitation. Their activity is developed logically from 
their ideas and from their mood even when in itself it is 
ever so nonsensical, while frequently in dementia praecox 
very sudden impulses, not explicable even to the patient 
himself, interrupt the inner connection of psychic events. 

Monotonous lamentation of anxious patients must not be 
allowed to mislead to tlie assumption of catatonic stereotypy. 
The constant return of the same utterances and gestures is 
here not the result of senseless, perseverating impulses, but 
the expression of a permanent emotional reaction dominating 
everything, which continually produces the same ideas and 
tries to express itself by the same expedients. It is true 
that the originally intelligent movements and utterances in 
the course of time show a certain rigidity, pulling, tripping, 
arranging, rhythmic screaming. A female patient for years 
imitated the movements and noises of the wild animals into 
which she thought she was transformed. As a rule it will 
be possible to demonstrate their origin from ideas and 
emotions in contrast to the purely impulsive senseless dis- 
charges of volition in dementia praecox. 

Very important is the distinction of negativism from 
the anxious resistance and the inhibition of will in manic- 
depressive insanity. Even the behaviour at the approach 
and greeting of the physician permits certain conclusions 
to be made. The negativistic patient does not look up, 
hides himself perhaps, turns away or stares straight in front 
of him, and does not betray by any movement of a muscle 
that he is aware of anything. All the same he usually 
perceives better than the manic-depressive patient, who 
indeed also perhaps remains mute and motionless, but still 
in his glance, in the expression of his face, in slight attempts 
at movement, acceleration of the pulse, flushing, stoppage of 
respiration, lets it be seen that he has felt the impressions. 
In the negativistic patients further we meet rigid resistance 
at every attempt to change their position, but only on actual 
interference ; on the other hand the patients endure simple 
or even painful touches and even dangerous threats (needle 



266 DEMENTIA PRECOX 

at eye) for the most part without defending themselves, do 
not fall into excitement, at most move out of the way, let 
the needle stuck into their eyelid remain sticking. Lastly 
the resistance may of itself or under the influence of prudent 
compulsion pass directly into automatic obedience. In the 
manic-depressive cases on the other hand resistance begins 
with the threatening danger, no matter whether a change 
of position takes place or not ; nor do the limbs moved out 
of their position take up again with inviolable tenacity 
exactly the former attitude. At the same time a threatening 
approach leads to lively expressions of emotion, to screaming, 
evasion, anxious defence. 

The stuporous catatonic usually moves little or not at all, 
especially not, if asked to do so. Persuasion has no result or 
it makes resistance still greater. But if he does do anything, 
which cannot be reckoned on, this happens without recogniz- 
able retardation, often even with uncommon rapidity, while 
in the patient suffering from inhibition, such actions, which 
require volitional resolves, are carried out slowly and hesitat- 
ingly, as can be demonstrated now and then even in quite 
simple movements or answers. Sometimes in inhibition it 
maybe demonstrated that well-practised speech utterances, as 
numbers, are run off without hindrance, while difficulties are 
increased as soon as the morbid ideas are touched on, a sign 
that emotional influences play an authoritative part. Many 
a movement which is asked for remains wholly undone, yet at 
least preliminary movements for the desired action (slight 
movements of the lips, twitching of the fingers} are frequently 
seen, especially if the inhibition is gradually overcome by 
powerful persuasion. Contrariwise in catatonics one may 
observe how the impulse, at first perhaps appearing, is there- 
upon abruptly interrupted, made retrogressive, perhaps even 
turned into its opposite. 

For distinguishing the states of excitement of dementia 
pra^cox from vuinic seiziwes, it must first be noticed, that the 
faculty of perception and ordinary sense are usually more 
.severely injured in mania than in the former. While the 
patients even in the wildest catatonic mania are for the most 
part surprisingly clear about their position and surroundings, 
we shall always meet in severe manic excitement considerable 
disorder of perception, of thought and of orientation. In the 
agitated states of dementia pra;cox attention is scarcely 
occupied with the surroundings, although these are perceived 
quite well ; it is not easih' diverted. The manic on the 
contrary perceives inaccurately and" fugitively, and turns to 
anything new which enters into his circle of vision. Frequently 



DIAGNOSIS 267 

he speaks at once to the physician, overwhelms him with a 
throng of words, while the patient suffering from catatonic 
excitement does not trouble himself about the physician, 
simply continues his perpetual movement and can only by 
special exertions be brought to give a sensible answer. 

In dementia praecox again conversation is frequently 
altogether senseless and incoherent in spite of very slight 
excitement, while even in the most violent raving mania we 
seldom quite lose an at least approximate understanding of 
the manic train of thought. In the former there is also 
adherence to a few expressions going as far as marked verbi- 
geration ; on the other hand in the manic train of thought, in 
spite of the absence of all connection, the progression from 
one circle of ideas to another can still almost always be 
recognized. Speaking in a self-invented language occurs 
also in manics, but only in the form of boasting about foreign 
languages ; in the same way occasional neologisms appear as 
students' jokes and not, as in dementia pr?ecox, as derail- 
ments of expression in speech. A tendency to clang-associa- 
tions and rhyming, as well as flights of ideas, is peculiar to 
manic conversation ; on the other hand senseless monotonous 
jingling of syllables gives evidence for dementia praecox. 

Some of these distinguishing marks fall away in mania 
with inhibition of thought, in which the few and monotonous 
speech utterances as well as the vacant merriment make a 
complete impression of weak-mindedness, and therefore can 
bring the assumption of dementia praicox very near. How- 
ever, it has to do here with poverty of thought and conse- 
quently little substance in conversation, and not with unrelated 
incoherence and impulsive stereotypy. Laughing is often 
connected with external causes, and in the intervals isolated 
actions, more playful and merry than senseless, are inter- 
polated. 

Mood is in mania for the most part cheerful, merry, or 
irritable, but in dementia praecox, silly, convulsively unre- 
strained, or indifferent ; Dreyfus remarks that the hilarity 
of the manic has something infectious in it, in dementia 
praicox it has something repulsive ; it has no relation to 
the ideas of the patients. In the utterances of the patients 
with dementia pr?ecox there often continually appears even 
in slight excitement a deliberate obscenity, such as only 
occurs once in a way in manics in occasional outbursts of 
abuse. 

Further there has specially to be observed the aimlessness 
of the catatonic movements compared with the pressure of 
occupation of the manic, who invariably seeks relations with 



268 DEMENTIA PRyECOX 

his surroundings. In catatonics the movements are mono- 
tonous and are repeated innumerable times in the same way, 
while in manics being dependent on changing impressions, 
ideas and feelings, they usually always assume new forms. 
Not infrequently we meet in the excitement of dementia 
priecox a striking want of relation between pressure of speech 
' and pressure of movement, perhaps on account of the fact that 
they are here not brought into connection with each other 
by higher psychic processes. The patients may be in violent 
movement without at the same time saying a word, or they 
chatter incessantly without moving from the spot and even 
without lively gestures. Therefore here the pressure of 
movement is often limited to a very small space, perhaps a 
part of the bed ; the manic on the contrary seeks everywhere 
for an opportunity to occupy himself, runs about, busies 
himself with the other patients, follows the ph\'sician, carries 
on all sorts of mischievous tricks. To these are added the 
constrained and spreading nature of the movements, the 
mannerisms and nonsensical impulses in catatonia in con- 
trast to the natural, and to the healthy individual much more 
comprehensible, conduct of the manic. In other words, in 
mania perception, thought, orientation, are relatively more 
profoundly disordered than in the excitement of dementia 
pnecox, while in the latter it is specially emotions, actions, 
and speech expression which are injured in a peculiar way. 

Special difficulties in delimitation, as Wilmanns rightly 
brings forward, are presented by the mixed states of manic- 
depressive insanity. The differentiation of mania which is 
poor in thought from catatonic excitement has been already 
mentioned. In manic stupor the peculiarly cheerful mood, 
the lively, though concealed, attention to the surroundings 
with slight senselessness, the playful, certainly often scanty 
and empty remarks, the susceptibility to influence by per- 
suasion and external occurrences, lastly, the occasional 
purposeful, merry actions of the manic as opposed to the 
empty merriment, the indifference and the inaccessibility, 
the incoherent unrelated conversation, as well as the non- 
sensical, monotonous, impulsive discharges of volition in 
dementia praicox might usually after considerable observation 
make the differentiation possible. For the correct interpreta- 
tion of the remaining mixed states suitable points of view 
can be gained from the consideration of the individual 
disorders which compose them. 

The content of the delusions offers in general few effective 
points for the differentiation of the two diseases here 
discussed. Delusions of sin, ideas of persecution, hypochon- 



DIAGNOSIS 269 

driacal ideas may in both appear in very similar forms. 
Exalted ideas will mostly only be met with in manic- 
depressive insanity when other indications also of the manic 
state are recognizable. The delusion of physical, specially 
sexual, influence points with great probability, the idea of 
influence on thought and will almost certainly, to dementia 
praicox. Thomsen points out that the delusions in manic- 
depressive insanity have more connection with one another, 
have more inner unity, while in dementia praecox they are 
more changing, more incoherent. The nonsensical character 
of the delusions must not be immediately regarded as a sign 
of mental weakness, still in manic-depressive patients it is 
usually connected either with very lively emotional participa- 
tion or with dreamlike confusion. Where these accompany- 
ing phenomena are absent and exalted ideas are connected 
with the delusion of influence on will and perhaps persistent 
vivid hallucinations of hearing still exist, the assumption of 
dementia praicox will be justified. 

The recognition of dementia praecox is often made specially 
difficult by its course in isolated attacks separated by 
approximately free intervals. If the clinical picture of the 
state is not wholly unequivocal, the question in such cases 
will always have to be raised whether it is not a case of 
manic-depressive insanity, specially if at the same time states 
of depression also alternate with those of excitement. 
Thomsen has rightly called attention to the fact that the 
course of a single period of manic-depressive insanity in 
general is usually more even. Sudden and abrupt change of 
the states, as also shortness and irregularity of attacks and 
intervals, specially with more frequent recovery, will arouse 
rather the suspicion of dementia praecox. But above every- 
thing the conduct of the patients during the periods of 
improvement will have to be considered. Apparent complete 
restoration, clear insight into the nature of the disease, return 
of former efficiency, absence of all peculiarities in action and 
behaviour, will make manic-depressive insanity probable, 
though not absolutely certain. On the other hand the 
persistence of those peculiarities, which we formerly became 
acquainted with in the discussion of remissions, allows the 
conclusion to be made that dementia praecox is present, 
conduct sometimes quiet and constrained or inaccessible and 
repellent, sometimes irritable and self-willed or capricious 
and peculiar, emotional dulness, loss of endeavour and 
energy. Wilmanns has in the meantime properly drawn 
attention to the fact that shyness and embarrassment at the 
examination may simulate the disorders named, further that 



270 DEMENTIA PR/ECOX 

in certain circumstances it may be a case of vanishing 
morbid residua, lastly, that also in manic-depressive patients 
not infrequently between the attacks all kinds of abnor- 
malities are demonstrable. It is true that they might incline 
more to the states belonging to this disease, anxiety or 
depression, shyness, restlessness and perplexity, frequently 
also lack of clear understanding of the disease. 

Here it will not always be easy to arrive at a certain 
judgment from the evidence which is often so insignificant. 
Zendig after some years out of 370 cases of dementia pr.tcox 
searched out 127, in which the diagnosis had not appeared 
quite certain. He came to the conclusion that of them sixty- 
seven patients, the majority of whom were women, were to be 
regarded with greater or less probability as manic-depressive, 
because they exhibited no abnormalities at all, or at least 
only such as may be expected within the limits of the disease 
named. The result is, however, not final. My experiences 
have shown me that in cases with no very clear clinical 
morbid picture the possibility of dementia pra^cox may 
nowhere be left out of account, where after the attack of 
disease any changes at all of the psychic personality have 
made their appearance. Nevertheless attacks which have 
occurred many years previously, which have resulted in 
approximate recovery, but still more repeated attacks, 
especially those of contrasted colouring which have brought 
about no recognizable state of weakness will with rare 
exceptions justify the diagnosis of manic-depressive insanity. 

Hysteria. — Very frequently cases of dementia pra^cox are 
regarded as hysteria ' ; on the one hand the affected, often 
erotic, behaviour of the patients, on the other hand the 
appearance of hysteroid convulsive phenomena commonly 
leads to that. The drivelling terminal states with delusions 
are then perhaps termed hysteric insanity. Maggiotto 
reports that among 101 patients with the diagnosis of hysteria 
forty-seven turned out to be cases of dementia pnecox ; in a 
further series of 240 supposed hysterics there were forty-three 
similar errors in diagnosis. What distinguishes hysteria and 
dementia pra.'Cox from each other, is above everything the 
behaviour of the emotions. In hysteria we find a heightened 
susceptibility of the emotional life; in dementia pra;cox the 
susceptibility is lowered. In hysterics, therefore, we observe 
rapid, violent, and often even lasting influence by impressions 
emphasized by emotion, while the emotional reactions in 
dementia pra^cox are mostly shallow or of short duration and 
essentially independent of external influences. The permanent 

' Reyneau, Dimence pr^coce et hysteric. These. 1905. 



DIAGNOSIS 271 

inner relations to the occurrences of the external world, 
as they are developed in hysterics by the vivid emotional 
emphasis of the events of life, are in dementia praecox 
extinguished, or at least very much weakened ; the patients 
remain indifferent towards visits, surprising communications, 
exciting experiences, which in hysteria immediately find 
response in lively reactions. Stransky points out that the 
patients with dementia prascox even after the most violent 
excitement are at once able to fall quietly into deep sleep, 
while in hysterics the emotional reactions continue working 
for a much longer time. 

The resistance of the hysteric is not impulsive but it bears 
sometimes the stamp of angry irritability, sometimes that of 
childish defiance or affected coquetry ; it is not limited to 
passive resistance, as it mostly is in dementia praecox, but 
leads to outbursts of indignation and to defensive movements ; 
it can often be calmed by persuasion, in contrast to the rigid 
lack of susceptibility to influence of the catatonic. The 
affected behaviour of the hysteric arises from the more or less 
clearly felt need of being conspicuous and of showing off. It 
aims at working on the surroundings and is therefore 
definitely influenced by them and their behaviour, while the 
mannerisms in dementia prascox arise without purpose, even' 
constrainedly, and do not exhibit the slightest relation to the 
surroundings. 

Disconnected talk is carried on by hysterics only in 
dazed conditions with clouded consciousness and disorienta- 
tion ; on the other hand the incoherence of dementia praecox 
offers such a peculiar picture just because the patients for 
the most part are wholly clear. Moreover, in hysteric 
utterances of that kind the course of definite train.s of thought 
may usually still to a certain extent be followed, the con- 
nection with occurrences in the surroundings, experiences 
emphasized by emotion, dreamy imaginations ; while in 
dementia praecox it is a case of a senseless sequence of 
incomprehensible fragments of thought often with persistence 
of isolated component parts. Also in the speaking past 
a subject of the hysterics the relation of the evasive reply 
to the question put and, therefore, their mental working can 
usually still be distinctly recognized, in contrast to the 
utterances of negativistic patients, which as a rule are wholly 
disconnected. 

Genuine hallucinations in hysterics come under observa- 
tion only in dazed conditions or in half-waking states ; they 
occur far more in the realm of sight than in that of hearing, 
and are mostly of an exciting nature ; it is a case of 



272 DEMENTIA PR/ECOX 

threatening or beneficent figures in significant garments. 
The invariable appearance of hallucinations of hearing even 
by day excludes hysteria according to my experience, and 
gives decisive evidence for dementia pra^cox ; the same holds 
true for the undiscerning continuance in ideas of persecution 
and exaltation after complete disappearance of clouding of 
consciousness. This observation is probably in close con- 
nection with the circumstance, that in hysteria no weakness 
of judgment is developed, as usually meets us in such a 
striking way in dementia praecox in the unresisting giving 
way to the most nonsensical ideas in spite of perfect clear- 
ness. In hysteria whole regions of the psychic life may 
temporarily be forced out of connection with consciousness ; 
but still they go on working approximately as at other 
times, something like separated choirs. In dementia priucox 
that connection remains preserved, but the psychic faculties 
lose their mutual inner contact like an orchestra without a 
conductor. 

The seizures in dementia przecox are mostly fainting fits 
or epileptiform in character, still I have repeatedly observed 
seizures which wholly resembled those of hysteria. It m.ay 
be thought that here, as occurs in manic-depressive insanity, 
in epilepsy, in paralysis, in focal diseases of the brain, 
the morbid process in certain circumstances is also able to 
set in action psychogenic disorders. The stigmata of the 
hysterics will not usually be found in dementia praecox, still 
anaesthesia of the cornea, of the tongue, of the skin of the 
face, may be simulated by indifference and inattention, or 
by negativistic suppression of the reactions ; unilateral 
absence of sensation may be regarded as pointing to hysteria, 
as also circumscribed paralyses or contractures. The 
dyscestkesicF of the hysterics are usually changing and sus- 
ceptible to influence up to a certain degree ; those of 
dementia praecox are monotonous and obstinate, and other- 
wise than in hysteria are easily elaborated to nonsensical 
hypochondriacal ideas, or ideas of persecution. Occasionally 
I was able to assign morbid states, which at first looked 
quite like hysteria, to dementia pra.'cox, because the psychic 
reaction of the pupils was extinguished ; further observation 
confirmed this interpretation. Hiibner has reported similar 
experiences. 

Psychogenic Psychoses. — Special difficulties may arise 
for the correct apprehension of the morbid states in 
prisoners. Besides dementia praecox psychogenic forms of 
disease come under observation here, which may exhibit 
great external resemblance to it ; on the one hand there are 



DIAGNOSIS 273 

hallucinatory-paranoid states, on the other stuporous states. 
In the former probably above everything the absence of 
characteristic independent disorders of volition is to be 
emphasized. Mannerisms and stereotypies are absent, as 
also genuine negativism, which, however, in consequence of 
delusions, may be simulated by repellent behaviour. The 
patients are confused only in excitement, and when consci- 
ousness is clouded, but do not exhibit the incoherence of 
dementia pra^cox which continues even without emotional 
reaction and with complete clearness. As a rule hallucina- 
tions and delusions last comparatively only a short time and 
disappear soon on the removal of the patients to suitable 
surroundings, especially on their being taken from solitary 
confinement. Even when the delusions are not forgotten or 
corrected, there is still no further elaboration, and also no 
development of weak-mindedness and no decay of the psychic 
personality. The patients remain natural in their conduct, 
preserve their emotional activity and are able to take up 
their former life again. 

In states of stupor the patients are inaccessible, mute and 
resistive, like the catatonics, but it is usually easy to persuade 
oneself soon that their conduct is not impulsive, but is deter- 
mined by ideas and emotional reactions. They provide in 
an orderly way for the satisfaction of their needs, observe 
their surroundings, try to occupy themselves in some way or 
other, are clearly affected by external influences, and an 
increase of their stupor can at once be recognized as soon as 
one occupies himself with them. In contrast to that, nega- 
tivistic stupor in its rigid constraint exhibits, it may be, 
sudden and quite incalculable changes, but is in the highest 
degree independent of external occurrences. 

Dissimulation. — The silly, capricious behaviour, the re- 
pellent attitude and the speaking past the subject of nega- 
tivistic patients, further the absence of natural reactions to 
external interference, sometimes arouse the suspicion of 
deliberate dissimulation. In this domain the utmost caution 
is necessary. In several such cases, in which I believed with 
certainty that I had to do with undoubted dissimulation, I 
nevertheless saw dementia praicox develop later. Here 
inquiry must be made whether in the previous history 
morbid features in the sense of that malady have not already 
been demonstrable, whether an intelligible motive for dis- 
simulation is present, whether the phenomena have imme- 
diately followed the arrest or the sentence, whether they 
continue when the patient thinks he is unobserved, whether 
they are susceptible to psychic influences. If mannerisms, 

S 



274 DEMENTIA PRECOX 

stereotypies, or hallucinations of hearing appear, the assump- 
tion of dissimulation is of course unfounded. 

Epilepsy. — As in dementia prascox epileptiform seizures 
occur, the malady may be taken for epilepsy ; Nacke has 
described cases as "late epilepsy," which obviously were in 
substance dementia pr^ecox. For the most part, however, 
the seizures in dementia prsecox onh* appear as isolated 
phenomena, as precursors of the disease, or after it has existed 
for many years. Rarely it comes once in a while to an 
accumulation like a status in which the patients may succumb. 
Once I observed in a catatonic such frequent and regular 
epileptiform seizures, but with them also hysteroid seizures, 
that I was tempted to believe in a more chance connection of 
the two diseases without, however, becoming clear on the 
subject. Morawitz ' has described a series of similar cases 
with epileptic seizures existing from childhood, and he inter- 
prets them as epilepsy with catatonic features. The remain- 
ing phenomena of epilep.s}- are absent in dementia prascox. 
The weak-mindedness caused by epilepsy has also essentially 
different features. It is characterized by impoverishment of 
the range of ideas up to the most ordinary things of everyday 
life, limitation of the emotional relations to the welfare and 
the woes of the patient's own person and his nearest relatives, 
great weakening and imperfections of memory with preser- 
vation of orderly thought, action and behaviour. If with 
this is compared the incoherence of thought with fairly good 
preservation of memory, the general emotional dulness, the 
profound disorder of volitional action, as we meet it in 
dementia prascox, the differentiation of the states will not 
generally be difficult. 

On the other hand it has repeatedly happened to me that 
I have taken commencing catatonias for the dazed condition 
of epilepsy. To take the one for the other is especially easy, 
if perhaps a convulsive seizure has preceded. A point for 
differentiation may be given by the negativism of the catatonic 
as opposed to the anxious resistance of the epileptic. Percep- 
tion andorientation might for the most part be more profoundly 
disordered in the dazed state of epilep.sy than in catatonia. 
Senseless answers to simple questions, rapid and correct per- 
formance of commands point more to catatonia. In epilepsy 
the anxious or ecstatic mood usually lets it.self be clearly 
seen ; action is generally not so much impulsive as dominated 
by definite delusional ideas and feelings, which also come to 
light in conversation. Therefore we more frequently see 
the epileptic making assaults or attempts at flight or com- 
^ Morawitz, Klinische Mischformen von Epilepsie und Katatonie. Diss. 1900. 



DIAGNOSIS 275 

mitting deeds of violence, while the activity of the catatonic 
bears the characteristics of the senseless and peculiar, and 
betrays fewer relations to the surroundings. A certain 
stereotypy of speech and action may occur in both states, as 
also loss or clouding of memory. On the other hand the 
previous history generally, the further course always, will 
soon make the condition of things clear. 

Paralysis. — The delimitation of dementia prsecox from 
paralysis has lost almost all its former difficulties by cyto- 
logical and especially serological investigation. In the con- 
junction with lues, which occasionally occurs, we find, indeed, 
deviation of complement in the blood and perhaps increase of 
cells in the cerebro-spinal fluid, but never the VVassermann 
reaction in the latter which is so characteristic of paralysis. 
If further the physical symptoms of paralysis are taken into 
account, especially the reflex rigidity of the pupils, the dis- 
orders of speech and writing, the seizures accompanying focal 
phenomena, the distinction will usually be easy, particularly 
as the age of the patients also gives some evidence for the 
decision. The most important characteristics for the differ- 
entiation, which result from psychic findings, have already 
been mentioned in the section about paralysis. 

Amentia.^ — The states in dementia prsecox which are 
accompanied by confused excitement and numerous hallucina- 
tions, have often been called amentia and traced back to 
exhausting causes. Experience has shown me that cases of 
that kind cannot be separated from the remaining forms of 
dementia prascox according to the origin, course and issue. 
Only among the psychoses developing in immediate sequence 
to severe infectious diseases is there a group of cases to be 
differentiated, which in their clinical picture, as in their 
further development, deviate from dementia precox, and are 
caused by the toxins of infectious diseases. The points of 
view, which for their characterization as opposed to the 
disease here treated of come into consideration, have been 
discussed in the individual forms of infectious insanity. 
Laures- calls them by the name " demence precoce acci- 
dentelle " in contrast to the real " demence precoce constitu- 
tionelle " ; this in my opinion is not expedient and leads to 
error. 

Cerebral Syphilis. — Considerable difficulties, which at 
present cannot always with certainty be overcome, may arise, 
when there is a question whether certain acute hallucinatory 
states of excitement in patients demonstrably syphilitic ar^ 

^ Confusional or delirious insanity. 

- Luures, La confusion mentale chronique et ses rapports avec la demence 
precoce, 1907. 



276 DEMENTIA PR.^iCOX 

to be regarded as the expression of syphilis or of dementia 
praecox by chance accompanied by syphilis. A series of 
such cases have occurred in my experience ; in all of course 
paralysis could be excluded according to the points of view 
expounded above. Here the demonstration of bodily 
symptoms seems to me to be of importance, which may point 
to the existence of a cerebro-spinal syphilis (lymphocytosis 
of the cerebro-spinal fluid, disorders of the pupillary play, of 
reflexes, paralyses of the ocular muscles, disorders of speech 
and writing, pareses, seizures), on the other hand the absence 
of independent disorders of volition (negativism, mannerisms, 
also stereotypies), further of torpor, and the preservation of 
emotional activity. All these symptoms would give more 
evidence for a syphilitic foundation for the morbid state, as 
also conspicuous improvement of the same under specific 
treatment. In the rare cases in which once in a while in a 
case of focal disease of the brain " catatonic " symptoms are 
observed, the demonstration of the focal phenomena should 
keep us from the assumption of dementia prsecox. 

Paranoid Diseases. — At present the delimitation of 
dementia praecox from certain paranoid diseases appears 
least of all to be cleared up. Genuine paranoia itself is 
certainly not easily mistaken for it. In paranoia above 
everything the independent disorders of volition are absent. 
While our paranoid patients because of the regardless 
folly and danger of their- activity usually very soon come 
into conflict with their neighbours and with the public 
authorities, true paranoiacs usually control themselves so far, 
that more serious collisions with other individuals, as with 
public authorities, are avoided ; they preserve also in the 
essentials the capacity of managing to a certain e.xtent in 
the struggle of life. Their actions and behaviour appear 
only in so far abnormal as they are the outcome of their 
delusions ; for the rest they are mostly commonplace and in- 
conspicuous. Negativism, mannerisms, stereotypy, confusion 
of speech, neologisms are completely absent, as also the 
phenomena of influence on will. To that has to be added 
that the patients do not suffer from hallucinations, that 
their delusions are not incoherent and nonsensical, but 
connected and mentally elaborated, that the emotional 
reactions have suffered no loss. 

In the further course also it is seen that destruction and 
finally disintegration of the personality does not take place 
as in dementia praecox, that much rather the inner unity of 
the psychic processes remains permanently preserved. If 
we see the patients after five or six years again, the\- appear 



DIAGNOSIS 277 

in essentials unchanged, perhaps a little more resigned and 
by all kinds of experiences of life made more mellow, but 
with the old ideas, perfectly reasonable and well-balanced 
in conversation, bearing, and behaviour. The paranoid 
patients in dementia praicox in favourable cases repudiate 
their former delusions, yet have become shy, quiet, indifferent, 
weak of will. Or they bring forward other similar ideas but 
in a more disconnected, more extraordinary form, without 
proportionate emotional emphasis, contradictory, without 
mental elaboration, without essential influence on endeavour 
and action. But just as frequently they present the picture 
of one of the terminal states described with its many 
fluctuations, and are incoherent, silly, manneristic, negativistic 
or dull. 

The differentiation of paranoid dementia praicox from 
the similar alcoholic and syphilitic morbid states we have 
already tried to make clear in another place. The reasons 
why we have thought that we should give some other forms 
of paranoid diseases an independent position, we shall 
explain in the next section. Unfortunately there we shall 
frequently have to move on very uncertain ground. 



CHAPTER XII. 
HOW TO COMBAT IT. 

As we do not know the actual causes of dementia prrecox, 
we shall not be able at present to consider how to combat 
it. Lomer has, it is true, proposed as a heroic prophylactic 
measure bilateral castration as early as possible, but scarcely 
anyone will be found who would have the courage to follow 
him. Besides Henneberg in a case of pseudo-hermaphroditism 
saw just after the removal of the testes, which were situated 
in the inguinal region, a paranoid psychosis develop, which 
probably belonged to the domain of dementia pra-cox. One 
of my patients, a physician, who castrated himself, experienced 
no improvement of his condition by it. 

Bruce in connection with his discovery of a streptococcus 
tried without success the iimnunization of a patient by 
sensitized goat's serum ; in another case beginning acutely 
he used dead bouillon cultures with favourable effect accord- 
ing to his report. In the meantime we shall regard this 
attempt also with expectancy. The same may be said of 
the partial excision of the thyroid gland, which was carried 
out by Berkley in ten cases and is said to have resulted in 
six in improvement or recovery. He thought that by re- 
section of a lobe of the thyroid gland he would increase the 
blood-supply to the parathyroid glands, and he recommends 
the administration of lecithin at the same time. This pro- 
cedure has been several times repeated, by Judin in two 
cases, by Kanavel and Pollock in twelve cases, by van der 
Scheer in seven cases, almost always without result ; only 
van der Scheer saw improvement in two cases of which the 
one ran its course with Basedow's phenomena, the other 
exhibited struma. Pinheiro and Riedel report somewhat 
more favourable results. Pighini saw on administration of 
parathyroidin improvement of the pulse and of the disorders 
of metabolism which were found by him. Many years ago 
I endeavoured for a long time to acquire influence on 
dementia pra-cox by the introduction of preparations of 
every possible organ, of the thyroid gland, of the testes, of 
the ovaries and so on, unfortunately without any effect. 



HOW TO COMBAT IT 279 

Prophylaxis. — In children with such characteristics as we 
so very frequently find in the previous history of dementia 
prascox, one might think of an attempt at prophylaxis, 
especially if the malady had been already observed in the 
parents or brothers and sisters. Whether it is possible in 
such circumstances to ward off the outbreak of the threaten- 
ing disease, we do not know. But in any case it will be 
advisable to promote to the utmost of one's power general 
bodily development and to avoid one-sided training in brain- 
work, as it may well be assumed that a vigorous body grown 
up under natural conditions will be in a better position to 
overcome the danger than a child exposed to the influences 
• of effeminacy, of poverty, and of exact routine, and especially 
of city education. Childhood spent in the country with , 
plenty of open air, bodily exercise, education beginning late 
without ambitious aims, simple food, would be the principal 
points to keep in view. Meyer, who regards dementia 
prascox essentially as the effect of unfavourable influences 
of life and education on personalities with abnormal dis- 
positions, hopes by all these measures to be able to prevent 
the development of the malady. 

Treatment of Symptoms. — With regard to the main 
point we see ourselves for the present thrown back solely 
on treating the phenomena of the disease already present. 
Firstly in the cases which arise acutely or subacutely the 
placing of the patient in an institution is necessary to prevent 
accidents and suicide. Rest in bed, supervision, care for 
sleep and food, are here the most important requisites. In 
the states of excitement prolonged baths are suitable, the 
employment of which, it must be admitted, often meets with 
great difficulties, as the patients do not remain in the bath, 
but always jump out again, perform neck-breaking gym- 
nastics, roll about on the floor. The next thing now to be 
tried is to quiet the patient so far by a sedative, hyoscine, 
sulphonal, trional, veronal, that he may remain some hours 
in the bath ; he then usually soon becomes accustomed to it, 
and now, while whirling, splashing, plunging, turning round, 
gesticulating, only makes passing attempts to leave the warm 
water and lets himself be brought back again to it without 
difficulty. 

If in very severe and lasting excitement this procedure is 
unsuccessful, the best expedient, which invariably after a 
longer or shorter time leads to the goal, is the employment of 
moist warm packs. After a preliminary resistance of short 
duration the patient usually with surprising rapidity consents 
to these measures, even if, as with us, the coverings are on 



28o DEMENTIA PRyECOX 

principle not fastened. If he unrolls himself, as happens 
fairly soon at first, the attempt is again made to keep him in 
the bath, and, if the restlessness makes that impossible, the 
pack is renewed. This procedure in severe cases, helped in the 
beginning by sedatives, is continued day and night without 
interruption, but so that after at longest two hours the pack 
is exchanged for the bath, and the patient after one or two 
hours only then returns to the pack, if he will by no means 
remain in the bath. By such a regulated continuous change 
between pack and bath the most severe states of excitement 
are usually so far moderated after a few days that the simple 
bath treatment, or even, if at first only temporarily, rest in 
bed is possible. Care for regular feeding in very reduced, 
sleepless, resistive patients, in certain circumstances by the 
stomach-tube, is requisite, as also the regulation of the bowels, 
and the cleansing of the mouth, which is often encrusted by 
the continuous screaming and speaking. 

During states of stupor the continual refusal of food 
may make tube-feeding necessary ; frequent weighing is here 
indispensable. Likewise the regular evacuation of the bowels 
has to be kept in mind, and because of the negativistic 
retention of urine, which sometimes occurs, of the bladder as 
well. The uncleanliness of the patients, which is often great, 
demands the most careful attention. The danger of inten- 
tional and unintentional self-inflicted injuries can be met to a 
certain extent by the use of a padded bedstead ; but in spite 
of that it often enough still happens that there are skin- 
abrasions, bruises, furuncles, and .so on, which then show the 
usefulness of the employment of the prolonged bath, and in 
certain circumstances demand surgical treatmer.t. 

As soon as the acute disorders disappear, the main thing 
is to preserve as far as possible what the disease has not 
destroyed. Often the return to the family is now possible 
and even suitable, if the circumstances are to some extent 
favourable, and if states of excitement, uncleanliness, refusal 
of food, and similar more severe phenomena have not 
remained behind. Bleuler without hesitation advises early 
discharge, as he, in part probably because of his views of the 
unfavourable action of certain complexes, fears that the 
patient might "shut himself up." It is indeed the case that 
the removal to another ward or institution, or to former 
circumstances, sometimes exercises a surprisingly favourable 
influence. The patients who up till then had been perhaps 
wholly mute and inaccessible begin already on the journey 
home to converse with strangers in the train, .stop refusing 
food, go without making any fuss to their accustomed work at 



HOW TO COMBAT IT 281 

home. Further it must be acknowledged that the monotonous 
daily routine of institutional life, which relieves the patient of 
all independent activity and of all thought for himself, 
secures to him, it is true, far-reaching protection, but at the 
same time must also have an enervating influence and above 
everything must to a high degree blunt intellect, emotion and 
volition. To these considerations there is certainly opposed 
the difficulty that many patients are dangerous to themselves 
or to their surroundings, or are quite helpless and in need of 
careful attention. Nevertheless many of the more difficult 
patients behave themselves at home surprisingly well, so that 
one does not need to be too anxious about experiments in 
discharge. In the case of female patients, however, the 
danger of pregnancy, if there is not careful oversight, is to be 
guarded against. Where it is possible, before the discharge 
to the patient's own home, care in a family under medical 
supervision will first be tried. 

Occupation. — With all our measures we can meantime 
not prevent the great majority of those who are psychically 
crippled or half-crippled after dementia prsecox gradually 
being gathered into large institutions and homes for the 
insane, and these patients, as they do not quickly die off, 
and often pass their v/hole life in the institution, form the 
great mass of the insane who require to be cared for. What 
is necessary for them is occupation, which alone can preserve 
by exercise the capabilities which still remain to them, and 
prevent them from wholly sinking into dulness. For them, 
therefore, perhaps still more than for other forms of disease, 
colonies for the insane^ with their manifold opportunities for 
work and treatment on general lines, preserving independence 
as much as possible, are a blessing which can scarcely be too 
highly valued ; family care also plays for them an important 
part as a transition to discharge or as a permanent shelter, 
Frequentl}- one sees even very demented patients still 
cheerfully and usefully employing the remains of their 
capabilities which the disease has left to them, in a circum- 
scribed domain, in field and garden, in cowstall or workshop, 
in sawing wood and cutting fodder, in copying, drawing, 
reading, in cooking, washing, or in the ironing-room, in 
housework, or in the sewing-room. In the states of excite- 
ment, which occur very frequently, it usually suffices to 
remove them, temporarily, to supervision and rest in bed. 

Leucocytosis. — Not altogether infrequently one sees the 
psychic condition of the patients essentially improve under 
the influence of a fever, even in terminal states which have 
already lasted a long time without change. Irritable and 



282 DEMENTIA PR.-ECOX 

repellent patients give intelligent information and become 
more accessible ; negativistic patients appear more docile 
and obey medical orders ; in paranoid patients the delusions 
pass into the background ; dull patients apparently wholly 
demented show a surprising appreciation of the occurrences 
in their surroundings and bring all kinds of old memories 
to light. Unfortunately, with the disappearance of the 
bodily morbid state, this improvement usually very soon 
gives place again to the former behaviour. It is meantime 
a sign that even very profound dementia is not absolutely 
the expression of unalterable destruction, but up to a certain 
degree is still capable of amelioration. It might be thought 
in a similar way, as has been tried in paralysis, here also to 
imitate the natural process described, yet the few attempts 
in that direction hav^e as yet not yielded any very encourag-- 
ing result. Thus Itten from this point of view has tried in 
nine patients injections of sodium nucleinate. Nothing was 
obtained ; the same is true of some similar attempts, which 
I made myself. 



CHAPTER XIII. 
PARAPHRENIA.! 

The disintegration of the psychic personality is in general 
accomplished in dementia pra^cox in such a way that in the 
first place the disorders of emotions and of volition dominate 
the morbid state. In contrast to that we have now to take 
into consideration a comparatively small group of cases in 
which, in spite of many and various points in common with 
the phenomena of dementia praecox, but because of the far 
slighter development of the disorders of emotion and volition, 
the inner harmony of the psychic life is considerably less 
involved, or in which at least the loss of inner unity is 
essentially limited to certain intellectual faculties. The 
marked delusions, the paranoid colouring of the morbid 
picture is common to all these clinical forms which cannot 
everywhere be sharply separated. At the same time there 
are also abnormalities in the disposition, but till the latest 
periods of the malady not that dulness and indifference 
which so frequently form the first symptoms of dementia 
praecox. Lastly, activity also frequently appears morbidly 
influenced, but essentially only by the abnormal trains of 
thought and moods ; independent disorders of volition not 
connected with these, such as usually accompany dementia 
prrscox in such multifarious forms, only come under observa- 
tion by indication once in a while. 

The grouping of these paranoid attacks, as well as their 
delimitation from other similar states, presents the greatest 
possible difficulties. We know indeed that isolated morbid 
phenomena themselves only furnish us with very unreliable 
means of delimiting forms of disease. It can here, therefore, 
only be a case of a first tentative attempt to break up the 
various paranoid morbid types into groups. If a consider- 
able number of cases which are accompanied by permanent 
delusions are examined carefully, and if the alcoholic and 
syphilitic forms are excluded, it will always be found that a 
very considerable part of these, according to my experience 
about 40 per cent., within a few years exhibit the character- 
istics of dementia praecox. A further somewhat larger part 

^ See Introduction, p. i. 



284 DEMENTIA PR/ECOX 

falls to the paraphrenic forms which are to be described here, 
the rest essential 1\- to real paranoia. 

Among the paraphrenias again about half exhjbit that 
slow but continuously developing mixture of delusions of 
persecution and of exaltation, as Magnati has described 
them under the name of "delire chronique a evolution 
systematique." ^ Certainly this Magnan's disease, as far as 
can be judged from the descriptions given, is according to 
the views brought forward here probabh' not a clinical 
entity ; we should thus reckon many cases with marked 
mannerisms and numerous neologisms which rapidly end in 
weak-mindedness to the paranoid forms of dementia prrecox 
without hesitation. But at the same time " delire chronique " 
in its developmental forms with their slow course stretching 
over decades, einbraces a series of cases which form the 
nucleus of the first paraphrenic morbid group to be discussed 
here. As the French word "delire'" has a different meaning 
from our term "delirium," and as also the name proposed by 
Mobius for the morbid state, "paranoia completa" no 
longer corresponds with our views of to-day. I prefer to 
speak, supporting myself on Magnan, of a "paraphrenia 
systematica." Associated with it then there are as smaller 
groups, perhaps nearly related to each other, the expansive 
and the confabulating form of paraphrenia ; the last form, 
the fantastic, appears to hold an exceptional position. 

Pakai'hrenia Systematica. 

Paraphrenia systematica is characterized by the extremely 
insidious de^'elopmetit of a continuously proi^irssive delusion of 
persecution, to which are added later ideas of exaltation icithout 
decay of the personality. The beginning of the disease often 
consists of a change very slowly accomplished in the conduct 
of the patient. He becomes gradually quiet, sh\', sometimes 
more dreamy and absorbed, sometimes more distrustful and 
gloomy, withdraws himself occasionally carries on peculiar 
and incomprehensible conversations, is conspicuous in his 
behaviour, incalculable, capricious in his actions. From time 
to time there appears great sensitiveness and irritability ; 
the patient becomes on quite insignificant occasions im- 
moderately violent and malevolent, exhibits embittered hate 
and antipathy towards individuals in his surroundings, often 
towards his nearest relatives. Ideas of jealousy are specially 
frequent. 

In course of years a delusion of persecution becomes always 

' Magnan, Psychiatrische Vorlesungen, deutsch von Mobius; Heft i, 1891. 



PARAPHRENIA 285 

more and more clear. The patient notices that he is the 
object of general attention. On his appearance the neigh- 
bours put their heads together, turn round to look at him, 
watch him. On the street he is stared at ; strange people 
follow him, look at one another, make signs to one another ; 
policemen are standing about everywhere. In the restaurants 
to which he goes, his coming is already announced ; in the 
newspapers there are allusions to him ; the sermon is aimed 
at him ; there must be something behind it all. A patient 
thought that he must be watched from the church tower. 

The sentiments of the people round him appear at the 
same time to be anything but friendly. The inmates of 
the house look sarcastically at him ; they whisper and make 
mysterious sounds ; they separate from each other as soon 
as he comes. At the habitues' table in the restaurant he 
is jeered at ; queer things are said ; his companions are 
unkind ; they look askance at him, avoid him, greet him 
without ceremony, withdraw themselves from him. " It is 
noticed when anyone has fine feelings," said a patient. As 
soon as he enters a restaurant people begin to break up 
the party. People spit in front of him, clear their throats, 
cough slightly, sneeze in a conspicuous way, shuffle with 
their feet, ape his coughing, rush up against him. Detectives 
crowd round him ; he has the impression that he is under 
police supervision. Always and everywhere there are pin- 
pricks, everywhere chicanery and hostility. " It's never 
ending what goes on there," said a patient, " everywhere I 
see allusions, hints, a thousand things, which cannot be 
described, which must have been experienced in order to 
be understood." He also regarded a broken lamp-glass, the 
conferring of the military medal, as an intentional insult. 
Another patient made the observation that the number seven 
pursued him everywhere, and that his fellow-travellers in the 
train invariably were grouped in the figure of the Great Bear. 

Gradually the persecution becomes always more tangible. 
The patient cannot find rest any more ; tricks are played on 
him everywhere ; everything is done to spite him : people 
work systematically against him. The servants are incited 
against him, cannot endure him any longer ; the children 
have no longer any respect for him ; people are trying to 
remove him from his situation, to prevent him from marrying, 
to undermine his existence, to drive him into the night of 
insanity. Female patients perceive that people are trying to 
dishonour them, to seduce them, to bring them to shame. 
Secret affairs are being carried on in the house ; strange 
people are standing in the passage. The patient ascertains 



286 DEMENTIA PR/ECOX 

that his things are being stolen, that a " secret domiciliary 
visit " was held. The lock is forced ; his boxes have been 
broken open, his things rummaged through, thrown pell-mell, 
the furniture displaced. His bed is dirty ; his clothes are 
torn ; the stove is being blocked up, bad air let into the 
room, the water suddenly turned off; letters are being 
suppressed. The beer causes colic, the bread a burning 
in the brain ; there are poisonous vapours in the house ; 
there is a suspicious powder in the bed ; the doctor gives 
a blue medicine which without doubt contains prussic acid 
and is intended to cause the death of the patient. In 
consequence of this the patient feels himself "spied on" 
everywhere and threatened, not safe even with locked doors ; 
it is an unparalleled hounding, fraud, and deceit, " the whole 
affair is known in the town." " There's a constant uproar," 
declared a patient. Obviously there exists a regular con- 
spiracy that carries on the persecution ; sometimes it is the 
social democrats, the " red guard," sometimes the Free- 
masons, .sometimes the Jesuits, the Catholics, the spiritualists, 
the German Emperor, the "central union," the members of 
the club, the neighbours, the relatives, the wife, but especially 
former mistresses, who cause all the mischief. 

Hallucinations. — After this extremely tormenting state 
of distrust, uncertainty, and tension has continued as a rule 
for years, real hallucinations usually appear also, especially 
those of hearing. The patient hears whistling, false notes, 
weird noises, disapproving remarks, abusive epithets, threats. 
There is whispering going on, telegraphy, speaking through 
the telephone. A patient ascertained that the hallucinations 
ceased on his ears being stopped, another that they were 
present only at home but not when he was out walking ; 
both drew therefrom the wrong conclusion, that it could not 
be a case of mistake. Jews scream after the patient on the 
street ; people speak about him, call him foolish, a black- 
guard, filthy beast, old wretch, simpleton, court-prostitute, 
a bad lot, rascal, ragamuffin, criminal ; he is accused of 
masturbation, of murder ; it is asserted that he is impotent, 
that he is sexually filthy, that he brought his parents to the 
grave ; his son has been killed. A female patient heard her 
husband and her son lamenting " as if they were lying in the 
tower of purgatory undergoing penance " ; another noticed 
that she was jeered at because of her alleged sexual 
insatiability ; " It went like wildfire." Everyone abuses and 
persecutes him, everyone knows all the circumstances of the 
patient accurately. Sometimes it is not a case of sensory 
perceptions, but of "spiritual calls," "inspirations," "the play 



PARAPHRENIA 287 

of thought," " thought dialogue." The patients are made 
capable of that by hypnosis, are spiritually questioned, to 
which questioning they answer aloud or perhaps only 
inwardly. Now and then they notice their thoughts becoming 
loud ; others can hear it. A patient thought that his 
neighbours would be very much annoyed with his thoughts 
being said aloud ; another heard his thoughts whistled after 
him by locomotives. The voices also perhaps speak in the 
thoughts of the patient, criticize him, accompany his actions 
with remarks. 

Hallucinations of other senses play an essentially smaller 
part. The patient is " fooled with visions," sees skeletons, 
the devil, people who are dead, the Virgin Mary, bleeding 
sacramental bread, naked women. To a female patient the 
faces of people appeared changed ; she thought that people 
had put on masks or other heads. Food tastes abominably, 
stinks; the house is filled with peculiar smells; the clean 
linen smells of a chemist's shop. A patient complained of 
unnatural and painful sensations, felt mysterious stabs as of 
a dagger, thought that Satan was spitting on him ; another 
felt himself struck, rushed upon, pushed about ; a woman 
thought that she was being photographed with Rontgen rays. 
Female patients have sensations, pulling in the genitals, feel 
themselves spiritually married. 

Ideas of Influence. — The idea, which occurs not infre- 
quently, of hypnotic, magnetic, electric influences, may like- 
wise be frequently connected with bodily dysaesthesiae, sharp 
pains, twitchings, dragging pains, transmission of currents. 
Many patients make statements about influences on will. 
Suggestions are given to them by magnetism ; people want 
to have their thoughts ; people who are dead tell them what 
they must do. A female patient felt that a count had got 
her in his power ; she was as if paralyzed and must obey him, 
she could not eat at meal-times, became hungry at the wrong 
time, felt herself forced to buy clothes against her will ; she 
was not able to love her mistress any more, she had to be 
impolite to her. A patient declared that he would be forced 
to do certain actions but would only yield in insignificant 
things. Another thought that his will was being led : 
" Someone wants to do something to me. The whole force 
and persuasion from an unknown part — it is forced on me 
that I must think myself greater than I really am or was in 
everyday life till now." 

Exaltation. — When the delusion of persecution has con- 
tinued for a number of years and has been developing by 
slow progression or, as happens much more rarely, after the 



288 DEMENTIA PR.tCOX 

disease has existed for only a short time, or in the beginning 
of it, the patient produces, sometimes rather suddenly, 
exalted fdeas. At first they may keep within fairly modest 
bounds. After being ill for some years a woman directed a 
letter to the emperor with the inquiry how she could be rid 
of her husband ; later she praised her own brilliant talk, her 
voice clear as a bell, her fine tact, her high endowment. 
Another female patient, who felt herself very much annoyed, 
thought that she must have a peculiar power in her eyes 
because people could not look at her. A third, after being 
persecuted for six years, supposed that some highly-placed 
personage must be behind it all ; a patient asserted suddenly, 
after he had suffered extreme torment for twent}' \ears, that 
some of his fellow-patients were marquises and princes, and 
he began to treat them with special reverence and to kiss 
their hands. 

Very commonly the patients make claims to money. 
From some source or another large sums should come to 
them which are being kept back ; they have been left an 
inheritance which has been suppressed. A patient thought 
that by going round "circular paths ' he would earn large 
sums, and daily he sought such paths and hoped so to acquire 
about 30,000 marks a month, which, he assumed, would be 
deposited for him regularl)' in the bank. A female patient 
thought there and then- that she must have an income ; 
another was convinced that an archduke had settled some 
money on her for her marriage. Apparently the)- derive 
their knowledge of such things most frequently from hallu- 
cinations of hearing in which their secret wishes come to 
expression. 

In a further group of cases it is an affair oi erotic relations 
with highly-placed persons. The patient notices that a lady 
of distinction is interested in him ; a picture postcard which 
he receives is obviously from her ; highly-placed persons 
approach him in all sorts of disguise. A duke made known 
to a female patient by hypnotic ways that he wished inter- 
course with her ; later she had " thoughts of love," that a 
married man wished to marry her, and she made all the 
preparations for her marriage. At the same time high- 
sounding titles are often attributed to the loved ones. 
The man last mentioned became a baron to the patient. 
Another female patient wrote letters to a man, also already 
married, with the address, "Peter the Great of Russia, in- 
cognito," and then made complaints at the post-office that 
the letters were not dispatched. Others exalt their enemies. 
A patient threatened that with the help of the pope he would 



PARAPHRENIA ^ 289 

put Bismarck in chains ; another supposed that the main- 
spring of all the troubles that came upon him was William II., 
whom he regarded as his personal enemy. 

But most frequently by far the exaltation in rank concerns 
the patient himself. He observes that he is being greeted by 
gentlemen of rank, that sentries show him marks of respect, 
that he is treated with peculiar distinction ; the policeman 
who travels everywhere after him is appointed by the 
Emperor for his protection. Someone or other addresses 
him as Count or Prince ; the waiters speak of Highness, of 
Elector ; immediately on his appearance they have a fresh 
barrel broached ; as soon as he begins to eat the lights go up. 
He perceives that the Emperor is interested in him, that 
princes also are in the affair, that aristocratic ladies send him 
letters and presents, which in an infamous way are suppressed ; 
a patient thought that he had himself seen the ladies throwing 
letters into the letter-box. Someone makes known to the 
patient that coins with the likenesses of his ancestors are in 
existence ; he hears allusions and learns through the telephone 
that a patent of nobility has been awarded to him, that at mid- 
night he will be publicly proclaimed a Count of the Empire. 
It becomes clear to him that he is of high descent, that his 
ancestors have played a great role, that he possesses great 
merit and rights. He can display gigantic capacity and 
knowledge, feels himself a political personage of the first 
rank, a member of the House of Lords and Vice-chancellor of 
the Empire, a relative of the reigning House, indeed the 
rightful ruler of the country himself; " Indeed the whole 
world knows that," said a patient. He is the "King's bastard," 
son of the Emperor Frederick, step-brother of Prince Charles 
P'rederick, is in communication with all monarchs, will marry 
Princess Katherine of Russia. A patient declared that he 
was emperor and pope in one person, ruler of the whole world, 
later also that he was immortal, that he had driven the 
capacity of decomposition out of his body by salt, and that 
he was a unique thing among human beings. A glimpse 
into this train of thought is afforded by the following frag- 
ment of a letter : — 

" Distress, grief, care and doubt make me have the most unrefresh- 
ing nights. I cannot be indifferent, and so the dumb, obdurate world 
is an oppressive burden to me, even though the star of my bliss is as 
large and glorious as the sun in the firmament. The black spectre of 
doubt, which often haunted me so dreadfully last year, causes me the 
question of the whole future, namely, immortality 1 Dear K. you will 
also be frightened about it, because no one as yet has remained in the 
world. But it is also evident and not to be refuted, that also as yet no 
one has been endowed with my qualities. For this reason it is certainly 

T 



290 , DEMENTIA PR/ECOX 

not absurd to think about it and to talk loud out, consequently even to 
believe, and the doubt, when it comes upon me, is no wickedness and 
no sin. I have not called forth this thought ; it came upon me suddenly 
as long as two years ago, in a moment when I went past the well in the 
garden, and immediately took complete possession of me, so that I was 
not able to ward it off. ... I am already advanced to the half of the 
usual age, and who has thought of laying down arms and surrendering 
at discretion ? Yes, certainly the world has enough cause to defy the 
Messiah ! Still with the truth it is to be hoped that I shall come out 
top over all fraud, and that everyone must acknowledge that I am the 
Lord, as Pharaoh learned. Let it be said, for dying I have not time so 
soon ; I must first beget or create looo million children, that is soldiers, 
and so they may defy. ..." 

In a small number of cases the exalted ideas acquire a 
somewhat i-eligious content, as already in the example just 
quoted. The patient is sent by God, is the protestant 
Joshua, speaks words of divine authority. \ female patient 
declared that she was a saint, she had the insight of a seer, 
could read the hearts of men, felt beforehand if anyone 
died, understood all the four faculties, was comforted by 
God ; another was called the bride of Christ. These 
delusions are often reflected in all sorts of hallucinations. 
The patient mentioned saw the child Jesus beside her bed ; 
the light of the monstrance fell on her. She heard God's 
voice which gave her commands and imparted answers to 
thought-questions ; she felt at night a warm breath and a 
face beside her, perceived copulation and then heard the 
child speak in her belly. The patient, from whom the 
document quoted originates, saw how the pictures of saints 
nodded to him, how a radiance shone from his forehead ; 
he heard the voice of his guardian angel, felt an invisible 
hand on his head, the pricks of the crown of thorns on his 
skull. Other patients hear hints that they are Emperor or 
Crown Prince, that they are in the middle of a pile of money, 
are to get one to two millions ; a female patient heard 
" supernatural things" ; it was said, "Thou shalt be the lion 
for the sin." On the other hand harmless perceptions are 
interpreted according to the megalomania. A patient 
asserted that the reigning prince had appeared in a restaurant 
for his sake disguised as a " field-worker " ; another saw a 
landlord make movements with his fingers and a guest 
shake his head in reply; he concluded from this that they 
wanted to signify to him that he should accept the sum 
offered to him. 

Ideas of exaltation and persecution frequently come into 
a certain relation to each other. Their conjunction is here, 
as in several other diseases, so frequent that it can hardly be 



PARAPHRENIA 291 

doubted that there is an inner connection between the two. 
It is usual to represent it in this way, that the elaborate 
arrangements which are made to injure them cause the 
patients to think that there must be some special reason 
connected with their person, or that the opposition, which 
stands in the way of the realization of their delusion of great- 
ness, engenders ideas of persecution. Sometimes indeed the 
patients give utterance to ideas which seem to point to such 
trains of thought. People are trying to get them out of the 
way, in order to be able to take possession of their great 
inheritance; people wish by "court intrigues" to hinder 
them from making an aristocratic marriage ; they are to be 
made willing by the traps laid for them to marry their 
persecutor. A female patient thought that her relatives 
wished to hinder her from marrying till she could no longer 
have children, in order that she might become a rich old 
aunt ; a patient who considered himself the rightful King of 
Bavaria stated that the plebs were hostile to him ; others are 
persecuted in order to prevent them from making known their 
just claims. Meantime the attempts at explanation proffered 
here by the patients, which moreover often completely break 
down, are hardly more than reasons thought out after the 
event ; otherwise, indeed, they would come to the surface 
much sooner. As we shall see later in the delusion of 
pardon in prisoners, a profound emotional disturbance last- 
ing for a very long time engenders by itself the tendency in 
some measure to take flight from inexorable reality to a world 
of pleasing illusions, a process that surely signifies a certain 
weakening of the psychic power of resistance. As it has to 
do with a progressive morbid process, it could be understood 
that the exalted ideas as a rule do not usually appear till the 
patient has become prepared in the hopeless struggle against 
hostile powers. 

The Perception of the patients is never disordered. They 
are clear about their surroundings and their position, if the 
misinterpretations caused by delusions are not considered. 
Understanding of the disease is completely absent, though a 
certain rnorbid feeling appears often to be present at least at 
the beginning. The substance of the hallucinations of 
hearing point to that ; it is not infrequently related to 
psychic disorder: "That's where the silly woman lives," 
" We're going to take him to the mad-house." Many 
patients feel themselves "driven to madness," made to have 
brain disease, made stupid, their enemies are to make them 
lose their understanding ; others try all sorts of experiments 
to find out whether it is a case of hallucinations or real 



292 DEMENTIA PR/ECOX 

perceptions. In the end, however, healthy deliberation is 
invariably overpowered by the morbid influences, and the 
patient remains completely deaf to reasoning. " I ride my 
nag and I do not give the reins to anyone else," a patient 
declared. A woman said " If I imagine everything, then I 
admit that I am a regular fool," but in spite of this she was 
not able to correct her ideas of persecution ; she looked on 
the supposed bad treatment in the institution as a sort of 
method of cure by which she should become accustomed to 
the persecutions outside. 

Pseudo-memories. — Memory and retention do not in 
general exhibit any disorders, but delusional pseudo-memories 
not infrequently come under observation. The patients 
report that already in their youth they were persecuted, 
that their experiences were already made public previously 
in the newspapers, were made known to them, usually with 
all details ; formerly they had not paid any attention to it, 
but it now occurs to them. A female patient asserted that 
she had repeatedly been hypnotized and assaulted, but had no 
idea of it till it now came into her mind again. The validity 
of their claims has formerly been confirmed to many patients. 
A patient reported that already in school he was addressed 
as Prince ; his grandfather said to him of William I., " Joseph, 
that is your grandfather." Later in the year 1886, he met 
the Emperor Frederick, who had a canula in his throat ; it 
was said to him that was his father. !t was made very 
plain to him everywhere ; his mother spoke of the Crown 
Prince ; in his sponsor's letter there was a large sum of 
money ; his aunt wrote to him on the death of the Emperor 
Frederick ; in the tramcar someone said, "That is the German 
Emperor." It was said, "Two emperors at the same time, 
that was a difficult birth," from which he concluded that he 
must have had a twin-brother. 

Exactly those kinds of delusional experience which one 
would at first be inclined to trace back to hallucinations often 
prove on more exact examination to be pseudo-memories. 
A patient narrated that many years ago a strange man had 
strewn poisonous powder on his forehead through the crack 
of the door; at the same time he heard a gold piece jingle 
as a sign that the man was hired by his enemies. Another 
patient affirmed that solemn promises were made to him 
in Parliament from the ministerial bench ; a third repeated 
a host of long conversations, which were connected with his 
claims to an inheritance, word for word with such detail, as 
is never possible in real hallucinations, but for pseudo- 
memories is characteristic. I quote here an example from his 



PARAPHRENIA 293 

numerous notes of the conversations alleged to have been 
heard by him relating to his claims : — 

" On the 2nd February I was at the funeral of A. at the Auerfried 
Cemetery. It was half-past two o'clock when I arrived. South from the 
old mortuary four people preceded me. Furthest to the left there was 
Joseph R., then his wife, beside her Mrs S., and furthest to the right a 
man unknown to me with his brown cloak. I was walking only a few 
steps behind them, and heard every word that was said. Mrs S. said, 
'Oh, how P. (name of the patient) looks; it's a veritable pity, and he was 
once such a capable workman ; how they have ruined him ; that is an 
abominable injustice.' Mrs R., 'And now they want to keep back his 
money from him too, and he is so much in need of it ; just look at him, 
how he looks, so pitiable ! ' R., ' Of course they would not want to give 
him the money ; they say he does not need it, but they must certainly 
give it to him ; but it will still come to light ; then they will be well 
punished.' The man on the right, ' Then doesn't he know anything of the 
business ?' Mrs S., ' He does know something but not rightly.'" 

Mood is at first for the most part anxious, depressed, 
even despairing, but then becomes more and more suspicious, 
strained, hostile, threatening. Later, when the exalted ideas 
come more distinctly into the foreground, the patients 
become self-conscious, haughty, scornful. They withdraw 
themselves from the people round them, avoid intercourse, go 
lonely ways, appear sometimes brusque and unapproachable, 
sometimes formally polite and dignified, but from time to 
time may also, where the delusional attitude to their 
surroundings does not come into consideration, be pleasant 
and accesiBible. In their spoken or written statements they 
are usually skilful and ready, give a connected and reasonable 
account of things, refute objections, and in doing so readily 
become impassioned and excited, or they are repellent, will 
not admit any explanation, declare that it is superfluous, 
everything is already known without it. 

The Activities of the patients are influenced in the most 
decided way by their delusions. It is true that many 
patients may continue to live for many years in their usual 
circumstances without specially severe disorders, but at the 
same time their whole conduct very soon shows the deep- 
reaching morbid change which has been accomplished in 
them. Apart from the fact that they shut themselves up and 
become gloomy and taciturn, they fall sooner or later into 
all kinds of disputes. They carry on loud soliloquies, they 
drum and knock on the furniture in the room, are irritated 
without recognizable cause ; they are abusive, they threaten, 
they make a noise at night. Many patients defend them- 
selves in despair against the voices, stop their ears, whistle or 
scream loudly to drown the sound of them. The voices said 



294 DEMENTIA PRECOX 

to a female patient that she should just be violently abusive; 
she was so aloud or in thought; that helped. A patient was 
forced by the voices to continual answering by the remark, 
" Silence gives consent." 

Often there are sudden attacks of anxiety. A patient 
called loudly for help at night, barricaded himself in his 
room, and passed a motion on the floor because he did not 
dare to go to the water-closet. The patients frequently 
change situation and place of residence ; a female patient for 
years moved from town to town and always after a few 
months made the discovery that she could not continue in 
her new home because everyone was already initiated. A 
patient tried to lead his persecutors astray by giving a false 
destination aloud on going out. 

Sometimes it comes to wholly nonsensical actions 
probably caused by delusions. A female patient stood for 
hours in the sun, washed herself in the water-closet, picked 
the skin off her face because small grains of sand-soap had 
penetrated it. A physician left his faeces on the table-cloth 
and gargled with his urine. Very commonly after some time 
the patients apply to the police, beg for protection against 
the annoyance, ask for an explanation of what they are 
accused of, put advertisements in the newspapers to defend 
themselves against supposed slanders, appeal to the public 
with a cry of distress. A patient ran through the streets in 
his shirt in order to force admission to an institution for the 
insane for the verification of his mental state. 

An idea of the struggle which the patients go through is 
given in the following fragments from letters which a patient 
threw over the walls of the institution in order to call the 
attention of passers-by to his circumstances : 

"When I came to Munich in the year 1875, 1 was brought by force to 
the institution for the insane here, for fear I might bring a complaint 
before the court, although according to a medical certificate and my 
certificate of service I was physically and mentally perfectly healthy and 
fit for work and no one could complain of me. As appears from my letters, 
complaints, and so on, my freedom is taken from me in this institution 
here principally for the purpose, though hitherto without success, of 
destroying in every possible way my mental and physical health, for 
which unprecedented crime the persons who took part in it are responsible. 
The institution for the insane is wrongfully used for the greatest crimes 
and serves especially the particular interests of unscrupulous physicians. 
I live here among wholly demoralized people, who for the most part avoid 
work, of whom several, as also the so-called attendants, gain their living 
by continually annoying and disturbing me by all sorts of misconduct 
and noise. . . . The superintendent of the institution avoids less and less 
every day the worst means to disturb me continually in my peace and 
where possible to get opportunity to have me still more under his power. 



PARAPHRENIA 295 

Every human feeling and decency are here trodden under foot. The 
physicians often pretend to be insane and to confuse nie with some other 
person. In the interest of order and justice I beg everyone to interest 
himself in my affairs and to bring them to public discussion." 

Self-defence. — As the inward tension increases, the 
patients who see themselves helpless and abandoned to 
persecution, often undertake self-defence. They call the 
offending individuals to account, or in petitions to the 
Emperor explain the whole of the mean fraud which is being 
carried on with them, or try by deliberate attempts to escape 
from the detention in the institution for the insane. They 
overwhelm a policeman with invective, suddenly box the ears 
of a harmless neighbour at table, by whom they fancy they 
are abused, throw stones at the passers-by, and finally make 
dangerous assaults on their supposed persecutors ; they 
become, as the French alienists call it, " persecuteurs 
persecutes." A patient shot his landlady from behind as she 
was passing, without further consideration, because he was 
convinced that she was going to put him in prison and incite 
others to murder him ; she had rattled with the keys in the 
morning, carried on a lively conversation with some neigh- 
bours who * were sick nurses, made signs and laughed 
sarcastically, so that he thought he was in the greatest 
danger. Some patients perpetrate attempts at suicide in 
order to escape from their persecutors. 

The exalted ideas may lead to all kinds of morbid actions. 
The patient goes to the bank to take out the sum standing 
to his credit, tries to get information about his descent at the 
registrar's office, suddenly makes a proposal of marriage, 
torments in every possible way his supposed beloved, who in 
spite of all refusals still continues to give him to understand 
by a flower that he is welcome to her. A female patient 
repeatedly tried to force her way late in the evening into the 
house of a married man to whom she asserted she was 
" civilly " married, and desired that he should immediately 
send away his wife out of the house and admit her to his 
wife's place. Other patients give conspicuously large sub- 
scriptions to public collections, write letters to highly-placed 
personages, go to the capital of the country to pay their 
respects to the sovereign or to bring forward their claims to 
the throne. A female patient asked the reigning prince by 
letter to find out the address of a washerwoman which she 
had not been able to get at the police office. A patient had 
visiting-cards printed with high-sounding titles, and sent tips 
to the policemen who had saluted him most respectfully after 



296 DEMENTIA PRyECOX 

his supposed elevation to the rank of baron ; he paid visits 
to the most varied governmental departments ; he gave 
advice in long documents about home and foreign politics, 
sketched out financial plans, appeared uninvited at a dinner 
of the federal council. Another asked the French minister 
Delcasse to place ten million francs at his disposal. Many 
patients are very fond of writing, and compose comprehen- 
sive petitions to the most varied authorities and personages 
not only about their own business but also about all possible 
other questions — about the overworking of horses, the break- 
ing up of the Sunday rest, the question of prostitution, plans 
for the improvement of the world. 

The Capacity for Work of the patients may be preserved 
for a long time fairly well. The above-mentioned patient 
who was about to shoot his landlady remained, in spite of the 
delusion of persecution, which had already existed for ten 
years, a diligent and useful worker. Others, after being ill 
for decades, still draw very creditably, write poems, produce 
contributions for magazines ; women can often conduct their 
household to complete satisfaction. A peasant boy when he 
felt himself called to be ruler of the world acquired a certain 
amount of knowledge of the Greek, Italian, Spanish, Russian 
and Latin languages one after the other. Nevertheless by 
the continued inner tension and excitement the capacity for 
regulated fruitful work in most cases gradually but materially 
suffers ; the frequent change of situation in consequence of 
the ideas of persecution also works unfavourably in this 
direction. Many patients finally give up serious work alto- 
gether, especially if exalted ideas begin to make their appear- 
ance ; they live a day at a time, read, dream, go walks, and 
wait for the fulfilment of their great hopes. 

The General Course of the malady here described is, as 
has been already mentioned, very slow, but still it progresses 
fairly continuously. Fluctuations of the state seem to 
appear only in limited measure. It is true that the patients, 
especially in immediate connection with the difficulties of 
life, are at times more excited or more anxious, and are 
then quieter again, but of real disappearance of the morbid 
phenomena there is scarcely a question, even if the patients 
perhaps are able temporarily to force their delusional trains 
of thought into the background or at least to conceal them. 

In the course of decades, however, a distinct change in 
the whole psychic conduct usually makes itself felt. It 
is certainly favoured by the circumstance that the patients 
because of their peculiar or dangerous actions and also their 
behaviour, after a shorter or longer space of time, usually 



PARAPHRENIA 297 

have to be placed in an institution and often suffer extremely 
by the deprivation of freedom. Their delusions, which 
receive fresh nourishment from it, become in this way 
gradually more nonsensical and more extraordinary. The 
patients are in a den of murderers, feel themselves worried 
in every possible way, are massacred by day and by night, 
assaulted, spied on with the microphone, chloroformed, 
tormented by Satan, suffocated by the stinking current 
and by electric poison rays. The physicians are in league 
with their persecutors ; they are being inoculated with 
syphilis ; varicose veins and furuncles are being produced 
in them ; their bones are being torn asunder electrically ; 
nocturnal emissions are caused ; attempts are made on 
their life with unscrupulous fury ; they are stupefied by 
poisonous pillows. In the institution there are secret 
passages ; patients are slaughtered and devoured ; the 
Emperor is deposed, dead ; a puppet has been put in his 
place; King Ludwig II. is still living. A patient made 
the announcement that a great assemblage of princes was 
taking place, in which the Prince Regent was kept prisoner, 
and people were continually being shot. On the other hand 
the patient has risen by degrees to always higher dignities, 
is in communication with all monarchs, has made 1600 
prophecies which have all been fulfilled ; he is the colleague 
of Jesus, the Lord God Himself, demands untold millions 
as compensation. His fellow-patients are counts and princes, 
aristocratic ladies who live in the institution on his account ; 
the nurses are hermaphrodites ; the physicians appear in 
different forms. The patient proclaims death sentences, and 
threatens to put everyone in jail, to make the military 
advance, and to have the institution shot to the foundation. 

In his behaviour he becomes assuming and flares up 
easily ; he overwhelms visitors with prolix explanations 
often rather vague ; at times he is abusive, indulging in 
the strongest language ; he finds fault, he is destructive 
and aggressive. Or he shuts himself up, goes his own 
way, buries himself in monotonous occupations, produces 
comprehensive documents with endless repetition of the 
same strains of thought, sometimes in bombastic style, 
with peculiar orthography and many flourishes in the 
calligraphy ; one patient painted lines or innumerable single 
letters. The form of expression occasionally becomes 
capricious, especially in excitement, the manner of speech 
affected. A patient thought that it was " a business got 
up that way by instigation " ; another on being accosted 
said that he did not let himself be " informed," he did 



298 DEMENTIA PRECOX 

not give up any right ; a female patient declared that she 
did not want the obscene cross ; another wrote : " All in all, 
also the cutting short or the complete cutting off of such to 
me honestly most happy time and times, which already since 
the year 1889 by God's grace was thus at our disposal, or 
thus becoming and shortened by such measures of arbitrary 
power and judgments. It is my last summons." A third 
asserted that she was subject to the annoyance of a vehmgericht 
and sun-dial. Playing with syllables also occurs; a lady 
analysed names into their syllables, distorted them, and said, 
" The name says everything (Esser-Ex-sex-Ex-sachs)." 

In spite of all this the patients remain, even after their 
malady has continued for twenty to thirty years, clear on the 
whole about time and place as well as about their position, as 
far as their delusions do not play any part, and also rational 
in their behaviour, here also apart from delusional influences. 
They are able to occupy themselves, to take up an attitude 
to the events going on around them, are even accessible and 
pleasant towards strangers who have no relation to their 
delusions, give information in a connected and compre- 
hensible way. But above everything they do not appear 
dull or silly, but are always interested, cheerful, and vivacious. 
Several of my patients knew how to convince completely 
one or other unreasoning member of their family of the 
reality of the persecutions and of their high claims. 

The Issue of the malady is a psychic decline with per- 
sistent delusions and usually also hallucinations without 
specially striking independent disorders of volition and with- 
out emotional dulness. Recovery does not appear to occur ; 
yet it may certainly be possible that isolated cases recover 
without being recognized. On the other hand higher grades 
of dementia are not reached ; even after very long duration of 
the disease, extending twenty to thirty years or more, it does 
not produce real disintegration of psychic personality. 

The share of the male sex was 60 per cent, in my cases. 
Rather more than half of the patients were at the beginning 
of the malady between the thirtieth and the fortieth year, 
a little over 20 per cent, between the fortieth and fiftieth 
year ; only isolated cases began before the twenty-fifth or 
after the fiftieth year. It is true, accordingly, for this disease 
also what we were able to establish in the delusional forms 
of dementia pnecox, that it attains to development only in 
riper years. This circumstance might arouse the suspicion 
that the clinical details perhaps depend more on the manner 
of reaction of the developed personality than on the peculi- 
arity of the fundamental morbid process. 



PARAPHRENIA 299 

Specially severe hereditary taint did not seem to me to 
be present ; I would, however, lay no weight on this, on the 
one hand considering the relatively small number of cases 
and also because of the circumstance that many of them 
reached back thirty to forty years and the previous history 
was therefore frequently incomplete. In a series of patients 
there was a report of peculiar disposition. Some were 
described as very pious, others as inclined to depression or 
as weak and sensitive, one as spiteful and malicious. One 
patient was regarded as very gifted ; another was a clever 
author inclining to be visionary ; a third an excellent chess- 
player. These experiences witness against the view of 
Magnan, who has tried to separate his "delire chronique" 
from the " mental disorders of the degenerate." The latter 
are said to be distinguished by rapid development, frequent 
change of state, conjunction of delusions of different kinds, 
and disappearance of auditory hallucinations relatively to 
those of the other senses. I have not been able to convince 
myself that these differences can be placed in causal relation 
to the existence or absence of degeneration. External causes 
for the outbreak of the disease I have scarcely ever found 
recorded ; in isolated cases the misuse of alcohol or infection 
by syphilis had preceded. We shall, therefore, bie able to 
assume rightfully that the disease is engendered by internal 
causes, but of what kind it is certainly not possible for us 
at present even to make a hypothesis. 

Delimitation. — It is above everything the permanent 
preservation of the psychic personality that has caused me 
to delimit the morbid group here described from Xhe. paranoid 
forms of dementia pra^cox. Certainly doubt is allowable 
whether this standpoint is justified. In dementia pra^cox 
also, especially in the paranoid forms, the disintegration of 
the personality may not take place, as we have seen in 
hallucinatory or paranoid weak - mindedness. But it is 
obvious that in those terminal states we have to do with 
morbid processes which have run their course and ended in 
recovery with defect, and just on that account these cases 
have not progressed to the more severe forms of dementia 
such as form the issue of other paranoid cases of dementia 
precox. We may well imagine, and may occasionally even 
really experience it, that a fresh outbreak of the disease 
may yet transform the hallucinatory or paranoid weak- 
mindedness into a drivelling, silly, negativistic or dull 
dementia. 

It appears that the circumstances are, however, somewhat 
different here. The disease does not after a few years 



300 DEMENTIA PRECOX 

remain stationary and then leave behind it an essentially 
uniform and permanent terminal state, but it progresses, 
even though very slowly, even after one or two decades, 
continuously, and almost never, or only after an uncommonly 
long duration, leads to an unchanging terminal state which, 
however, still scarcely injures the inner connection of the 
psychic personality. Against this it can certainly be said 
that we separated out only the cases of dementia pr.tcox 
which have a very slow and relatively mild course, and that 
indications of the disorders which we met there are by no 
means rare in the later periods of the malady, incoherence 
of the delusions, the use of odd expressions and silly puns, 
and influence on will. But, on the other hand, exactly the 
peculiarities of the course quoted, as the rarity and the 
slightness of the disorders mentioned, might be an indication 
that we have here to do with a peculiar morbid process 
different from dementia pra^cox. 

In the meantime it must remain doubtful whether the 
boundary line indicated here is sharp and whether it has 
been drawn at the right place. In any case it is often still 
very difficult at present to decide in the beginning of the 
disease whether it is a case of dementia pra^cox or of para- 
phrenia systematica. The evidence for the latter consists 
above everything in the very late appearance of distinct 
hallucinations in spite of a delusion of persecution which 
has existed already for many years, further in detailed 
mental elaboration of the delusions, liveliness and passionate- 
ness of emotional reaction, absence of independent disorders 
of volition, preservation of sense and of reasonableness in 
behaviour and action with delusions that are already 
advanced. 

We meet with almost as great difficulties as in the delimi- 
tation from dementia pr^ecox in the attempt to draw the line 
of separation in the direction of paranoia. As this task 
cannot be begun without first settling more exactly the con- 
ception of paranoia, which is still fluctuating inside the widest 
limits, we shall be obliged to postpone till then the discussion 
of the question. A separation on the extended territory of 
the psychoses which are accompanied by progressive delusions 
is, as shall be only indicated here, perhaps so far possible that 
we put on the one side those morbid cases in which we 
have reason to assume the course of definite morbid processes, 
while on the other side those forms would have to be placed, 
the causes of which we regard as consisting of the influence 
of the stimulus of life on morbidly disposed personalities. 
Whether and how far we are able from the <riven morbid 



PARAPHRENIA 361 

phenomena to draw conclusions a posteriori as to the one or 
other history of origin of the individual case will be elucidated 
later. 

Lastly, there has still to be considered in a few words the 
delimitation of the morbid state discussed here from other 
paranoid attacks. From the alcoholic forms it is distinguished 
above everything by its insidious development and its con- 
tinuously progressive course, while in the former we are 
brought into close connection with an acute, or at least a sub- 
acute, form of mental disorder and as a rule with the 
development of a psychic decline distinctly marked after a 
comparatively short time. Moreover in the alcoholic attacks 
hallucinations are in the foreground of the clinical picture 
from the beginning; in paraphrenia they only appear after 
years. Later also they play in alcoholic attacks an essentially 
larger part ; the morbid interpretations, suppositions, fore- 
bodings, on the other hand, wholly disappear. The condition 
of the mood is in drinkers more cheerful or indifferent, much 
less irritable and strained, than in the patients discussed here ; 
the phenomena of psychic weakness, senselessness of the 
delusions, disconnectedness in conversation, emotional dul- 
ness, docility, appear in the latter much more rapidly and 
more markedly. 

In syphilis paranoid attacks also usually assume striking 
forms considerably sooner than in paraphrenia ; also in them 
likewise hallucinations as a rule dominate the morbid picture 
already from the beginning. The delusions are far more dis- 
connected, not so systematized ; mood is much more changing 
and inclined to sudden explosive outbursts ; the patients are 
more accessible, more easily influenced. Their state is often 
subjected to abrupt fluctuations, in contrast to the obdurate 
stubbornness with which in paraphrenia all the morbid 
phenomena are continuously developing. The symptoms of 
psychic weakness in the syphilitic forms become much sooner 
noticeable, even if the delusions do not disappear. Added to 
that there are above everything the manifold bodily disorders 
caused by nerve syphilis and the demonstration of the 
Wassermann reaction in the blood. 

If we now consider the presenile delusion of injury, which 
as yet is still, it is true, very inaccurately delimited, there 
must specially be called to mind the indefinite and indistinct 
character of the delusions, which is peculiar to that form of 
disease. The delusions are not mentally elaborated ; they 
remain suppositions and fears engendered afresh at the 
moment and often changing ; they come and go, and can be 
displaced by persuasion, being quite different from the 



302 DEMENTIA PR/ECOX 

delusions in paraphrenia, which slowly take shape but then 
persist with great stability and become greater in extent. It 
must, however, not be denied that in the earh' prodromal 
periods of the disease this distinguishing mark may in certain 
circumstances be absent. 

The Treatment of the disease has naturally only very 
small scope. As the patients usually suffer very much in 
seclusion, which embitters them and furnishes fresh nourish- 
ment for their delusions, the attempt will be made, as far as 
possible, to arrange that they should be cared for in freer 
circumstances, possibly in a family or in the country. But 
unfortunately the disease frequently leads to actions which 
make institutional care indispensable. In these circumstances 
one will endeavour within the limits of necessary supervision 
to give the patients as much freedom as their state will 
allow, in order to counteract the withdrawal and shutting up 
of themselves, to which they are so much inclined. One will 
specially try to give them opportunity for occupation ; it is 
also advisable, as far as possible, to promote the intercourse 
of the patients with the outside world by letters or personally, 
as far as it is wished by them. In personal treatment great 
patience, composure and foresight are necessary. From time 
to time it may be expedient to avoid all contact with the 
irritated patients. Necessary interference (as in bathing, 
cleaning of the neglected room) must be carried out with the 
greatest forbearance but with firmness. 

Paraphrenia Expansiva. 

Of the smaller groups of diseases, to the discussion of 
which we now have to turn, the expansive form of paraphrenia 
is characterized by the development o^ exuberant viegalovmnia 
with predominantly exalted mood and slight excitement. The 
disease begins as a rule gradually, but also sometimes 
subacutely. Occasionally a period of anxiety and depression 
appears to precede ; an elderly unmarried woman believed 
that she was pregnant, and put on very thin skirts in order to 
conceal her state. The substance of the megalomania was in 
half of my cases erotic; it concerned exclusively female 
patients. The patient notices that a gentleman looks at her 
in such a peculiar way, smiles, makes signs to her, follows 
her, waits for her at the window. On the street remarks are 
let fall about it ; highly placed persons are interested in the 
affair ; the Virgin Mary gives a sign. Everyone knows 
about it ; the affair is the talk of the town. Ladies in grand 



PARAPHRENIA 303 

carriages drive past ; the military march through the streets ; 
automobiles come ; princesses turn to look at the patient ; 
the Court interferes. The advertisements in the newspapers, 
the pictures and articles, indeed even the speeches in 
Parliament contain allusions. A secret engagement with the 
" spiritual bridegroom " takes place, of which the patient 
learns from indications in the street ; she is greeted with 
great reverence. It becomes clear to her therefore, that there 
must be some special circumstance connected with her lover ; 
he is an officer high up in the service, a prince, indeed the 
King himself, or even the Pope. A patient wished to marry 
two kings at the same time; another asserted that she had 
been made pregnant by means of a glass of beer by the King 
of Spain who shortly before had actually been in Munich. 

In a second series of cases religious ideas of exaltation are 
in the foreground. The patients notice that people speak of 
them as of saints; the clergyman declares them from the 
pulpit to be such ; the monstrance bows ; they have at times 
a halo round their head. They receive inspiration and re- 
velations from God, possess the gift of prophecy, associate 
with Christ, are without sin, are mediator between God and 
mankind, are the instrument and daughter of God, can work 
miracles; they have received special grace, must co-operate 
in the redemption of the world, in the " final catastrophe." 
A female patient called herself heaven's bride, expected the 
angel-bridegroom ; she declared that she would be a priest, 
indeed that she was the third person of the Godhead. Another 
asserted that for seven and a half years she had been preg- 
nant by the Holy Ghost ; but God had declared that He did 
not wish to come into the world in the institution ; as soon 
as she got out it would immediately happen. A third stated 
that people could by a keen gaze pray diseases and sins on 
to her; the latter would then be prayed off and so mankind 
redeemed, while she would get rid of the former by sleeping 
or by diarrhoea with flatulence and pains ; in this way man- 
kind would once more be healthy. 

Along with this all kinds of other exalted ideas frequently 
appear. Above everything the patients lay claim to a great 
deal of money. Because they redeem poor souls by prayer, 
millions have been collected for them, which have been 
promised to them ; they are to get a house as well, the 
neighbouring house belongs to them. They are enormously 
rich ; there must be money there. " A queen without money, 
there is no such thing," said a female patient, who considered 
herself the wife of King Ludwig. Other patients remain 
permanently young, doubt whether their parents were the real 



304 DEMENTIA PR/ECOX 

ones, are of high descent, acquire great titles ; they are 
rulers of the world, man and woman at the same time, 
royalties, the fate of the world ; their knowledge is great and 
beyond all price, fills the whole world ; what they say comes 
to pass. A female patient had inspirations and therefore 
knew many things from God without anything being said to 
her, for example, the wishes of her master and mistress ; in 
this she almost never made a mistake. Another foretold the 
death of the Empress of Austria, wars, the appearance of 
cholera, the birth of princes in Russia and in Italy; she was 
therefore asked for advice by many people. King Ludwig 
was called back to life by prayer, is imprisoned in a castle ; 
a female patient led him to God and redeemed him. 

Hallucinations almost always appear fairly .soon. The 
patients have numerous visions, for the most part probably 
more dream-like, see the picture on the high altar trans- 
formed, the Holy Trinity, a man with a crocodile head 
fighting with Saint Michael, Christ on the Cross, the Child 
Jesus, the Virgin Mary on a tree, a monstrance floating in 
the air, a king's crown with Alpine roses and swans in the 
sky, erotic proceedings ; in the water of the fountain figures 
appear ; the light breaks out into flame as soon as they set 
foot in the church. At night the King comes; they speak 
with him, are asked if they would like to marry the Emperor, 
the King or His Royal Highness. Heav-enly voices ring 
out ; people call them saints ; the Pope speaks to them ; 
God, the Holy Sacrament, the Holy Ghost, give them con- 
tinually an answer to the question what they should do ; it is 
said low, only perceptible to themselves: " My dear child, do 
what I tell you ; you will be blessed." The neighbours 
whisper secretly, " Saint Anna," " Here comes the Saint," 
the affairs of the patients are talked about ; they hear every- 
thing that is said in the house. A female patient carried on 
"conversations in thought" with her supposed bridegroom; 
'' What he said I knew, and vice versa." Another heard 
dogs, birds, cattle, horses ; then also flies and pictures 
speak : they gave answer. The dogs were employed by the 
police to watch everything and to bark it out ; voices came 
also from the clouds. Sometimes it comes, as already 
indicated, to inward dialogues ; to thoughts there follow 
answers. 

From the description of herself which a female patient 
drafted of her visionary experiences I take the following 
fragments: — 

"So it came about that Satan left me no peace by night and I began 
thestruggle with him afresh. . . It was a hard struggle. But the luminous 



PARAPHRENIA 305 

cross of my Saviour and all the crosses of my suflferings (which also 
signify the sufferings of the world) killed him, for I stabbed his heart 
with all invisible cross-swords. There he lay dead, the dragon, the 
beast, the monster. But I took my stand with my last cross held high 
in my right hand on his paunch belly and cried three times with a loud 
voice: 'O death, where is thy sting? O hell, where is thy victory?' 
And when the serpent heard these things, it came slowly and sadly 
creeping, for it had no more strength ; it had lent it to Satan, that he 
might conquer me, and when I saw it I pierced its head with my last 
cross-sword, and it also did not move again. Morning had long since 
dawned. The birds brought their songs to our love. . . Easter ! 'Tell me, 
my father, why is it Easter for me to-day?' ' My child, my dear, good 
child, this night my resurrection took place, this night I took over the 
kingdom of my father. . .' Then came the night, a peaceful glorious 
night. But it was not to last long, my untroubled happiness, for he who 
before was the embodiment of Satan, who was then happy to be set free 
and called himself my bridegroom, he came spiritually to me, in order to 
take possession of the bride, but what did he take ? Not the spirit, as I 
hoped, no, my pure body ; he looked at me with a fearful lascivious 
grimace and said, ' Now you are mine, wholly mine "... But the old 
God laughed craftily and sang out of Wagner's Walkiire ; Blessing, 
laughing love, the bond of Siegmund and Sieglinde. Ha, even God 
helps me no longer ; even a God is turned into a swine. , . If in the end 
now God Himself wanted to flirt with you ! Ha, it drives one to 
desperation, to insanity ; but I tell you, old God, that I whistle at you 
and your help, and at your love too, if it is that kind. . . Touch me again, 
you abominable creature, and look I shall put this six-barrelled revolver 
in my mouth and discharge it, and I shall lie before you with a broken 
skull, a corpse, then go on playing with me if you want. . . ." 

Religious and erotic trains of thought are here spun out 
in high-sounding form to visionary pictures which were 
described by the patient partly as real events, partly as 
inventions. 

Ideas of Persecution. — Hand in hand with the megalo- 
mania there are invariably ideas of persecution, which, 
however, in the whole clinical picture do not acquire a 
dominating position as in the previous form. The patients 
have to pass through trials, are to be oppressed ; danger is 
threatening. They are being badly treated, being laughed 
at ; people spit in front of them, clear their throat, blow their • 
noses, threaten them with their fist, knock up against them 
on the street with packages, pour out water, knock at the 
doors, let the water run ; everyone is in the plot. The 
money that should come to the patients is withheld from 
them ; their letters are suppressed, their things are stolen. 
They are being poisoned, magnetized ; their thoughts are 
deciphered by the physicians by means of apparatus. 
People lie in wait for them, wish to abuse them sexually, 
their husbands wish to get rid of them in order to be able to 
enter undisturbed into improper relations ; dreams give cause 

U 



306 DEMENTIA PR/ECOX 

for jealousy. Rivals appear, force the loved one to marriage 
and to suicide. In the newspapers there are spiteful 
allusions ; wounded men and hearses come in sight ; acquaint- 
ances die ; it is as in war. 

Here also hallucinations may play a part. The dogs 
bark in such a peculiar way ; allusions are made to cases of 
theft ; abusive words, slanders are called out ; someone is 
calling for help ; at night Satan appears. A female patient 
was very much troubled by abuse and cries of the " Empress 
of Pekin." Occasionally dysesthesias due to strange 
influence are reported ; a female patient complained that a 
male teacher had " brought apparitions on " her. 

Pseudo-memories- — During this development perception, 
orientation, memory and retention are not" essentially dis- 
ordered in the patients, still pseudo-memories occur not 
infrequently. The prophecies quoted above depend on 
them. Many patients state that they had already known 
beforehand that they would come into the institution, also 
how things looked there ; they greet fellow-patients as old 
acquaintances. A female patient after many years re- 
membered, as she thought, a meeting with King Ludwig ; he 
treated her to beer and proposed to her that she should sleep 
with him at night. When she told her father about it, he 
laughed and said, " That has been King Ludwig ; you will 
get a large sum of money yet." Another female patient saw 
a paper on which the title of countess was granted to her. 
The people in the neighbourhood are often taken for other 
people in a delusional way ; they are princes and nobles ; a 
female patient for many years called the physician " Little 
uncle of Nassau," even after an absence of some years ; 
another woman called a female fellow-patient " her little 
Ludwig." Insight into the disease does not exist. The 
patients indeed occasionally, on remonstrances being made, 
retract some of the delusions to which they have given 
utterance, but immediately afterwards come with similar 
ideas again. A female patient, who discovered in the 
newspapers the most nonsensical allusions to her affairs, 
spoke of her " newspaper delusion," but at the same time 
continued her interpretations unswervingly. 

Mood is self-conscious, cheerful, often unrestrained and 
irresponsible. The patients are inclined to jokes and 
witticisms, or radiant and beaming with happiness. There 
are interposed times in which they are irritable, high-flown, 
presuming or distrustful, repellent. In their conduct they 
appear as a rule reasonable, accessible, pleasant, but easily 
fall into violent excitement if people occupy themselves for 



PARAPHRENIA 307 

a considerable time with them, fall into a preaching tone, 
let loose an enormous torrent of words, declaim, prophesy, 
abuse, threaten to make a whole regiment march up, give 
utterance to frightful curses. 

The Activities of the patients are often under the 
domination of their delusion. They try to approach the 
object of their love, write letters, answer advertisements in 
newspapers, make preparations for marriage. A woman 
sent the most high-flown love-letters to her husband's 
superior, and indeed to the care of his wife, as presumably 
she was directed to do in the newspaper. Another female 
patient for years remained an hour and a half every day 
sitting at her window, because she thought that otherwise 
something might happen to her beloved who lived opposite 
and had no forebodings ; she wrote to him as his wife and 
declared to her own husband that she wanted to be divorced 
from him. A third betook herself with a loaded revolver to 
a married physician, with whom she thought she lived in 
spiritual marriage, and threatened to shoot him and herself. 
Other patients try to come into possession of money that 
has been withheld ; a woman tried to force her way into 
the Royal Palace and cried aloud from the window that 
she would stab the sovereign because he did not pay to 
her the sums of money due for the salvation of 
souls. Another female patient went to Vienna to pre- 
vent by her prayers the plague from spreading there ; 
a patient suddenly ran to the altar during service and 
began to preach. 

Apart from such derailments and the more transitory, 
though often very violent states of excitement, the patients 
may appear quite inconspicuous and occupy themselves 
reasonably. Often, however, they display a somewhat 
affected, pompous, unctuous behaviour. Many patients 
compose comprehensive, bombastic, and turgid documents ; 
a female patient wrote in one of herself, " Myself, us — the 
most holy Majesty of God ! Sovereign and ruler of heaven 
and of earth ! Lord and Saviour-Imperator-Redemptor — 
of all princely families — in spite of my tender youth. . . ." 

In the Further Course the morbid picture as a rule 
only changes slowly, as far as I can judge from the few cases, 
which were observed for longer than a decade. The patients 
remain in general reasonable and clear, but adhere firmly to 
their delusions, which perhaps become somewhat more 
nonsensical and more disconnected. They are loquacious, 
verbose, distractible, at the same time lively, accessible, and 
docile; they exhibit a changing, predominantly confident 



308 DEMENTIA PRECOX 

and exalted mood, do not cause any special difficulties in 
medical treatment. Apart from great lack of judgment, 
a certain incoherence, superficiality of emotions, and weak- 
ness of volition, no profound dementia appears to set in, 
at least no disintegration of psychic personality. 

It is noteworthy that the patients whom I have described 
were almost all women. The commencement of the malady 
was in three-quarters of the cases between the thirtieth and 
fiftieth year ; one case began first at sixty-four years of age, 
without there being any possibility of senile dementia. No 
trace could be found of specially severe hereditary taint, 
and just as little of external causes of disease. One female 
patient was artistically gifted, another had always been 
excited ; a male patient was reported as very religious and 
with little mental endowment ; in several other cases also 
there had probably existed for a long time conspicuous 
features in the character. 

Delimitation. — Whether the morbid states brought 
together here as an experiment really constitute a clinical 
entity is doubtful. On the other hand I consider it almost 
certain that they cannot without difficulty be placed ip one 
of the morbid forms otherwise known to us. From dementia 
prcecox they are distinguished by the strikingly slight injury 
to the psychic personality even after a duration of many 
years in spite of the continued existence of the morbid 
phenomena, further by the absence of all independent voli- 
tional disorders apart from the affectation which is perhaps 
connected with the exalted ideas and from the indications 
of influence on will which appear now and then. Not un- 
important is perhaps also the circumstance, that here hallu- 
cinations of hearing and above everything bodily influences 
as delusional occurrences go completely into the background 
behind hallucinations of sight, interpretations, and pseudo- 
memories. This circumstance also plays a part for the 
delimitation from systematized paraphrenia. But to that 
there is added the usually more rapid development of the 
disease, and especially the mood permanently exalted in 
spite of the ideas of persecution which likewise appear, and 
the accessible, pleasant, natural behaviour. Obviously the 
patients are not in the remotest degree so tormented as the 
persecuted persecutors; the continual interference in their 
inner life which by those patients is felt as so extremely 
tormenting, is almost entirely absent in them. 

A number of the patients described here I considered for 
a long time to be manic. Their cheerful, often exultant 
mood inclined to jokes, and their prolix loquacity, as also 



PARAPHRENIA 309 

their outbreaks of excitement, which rapidly become worse 
by external stimulation, make this interpretation sometimes 
extraordinarily probable. However, it is a case here in the 
first place of only single attacks which moreover may without 
essential change continue for an unlimited time;' some of 
my observations extend over twelve, fourteen, eighteen years. 
Further, after a considerable time the gradual development 
of a state of psychic weakness with continuance of the 
delusion is unmistakable*. Lastly, the excitement is often 
very slight, may even be wholly absent, or be noticeable 
only on stimulation, so that the patients display nothing 
but an unreasonably cheerful and confident behaviour with- 
out in any way letting themselves be disconcerted by their 
delusions. As I suppose, these are the cases which caused 
Thalbitzer to bring forward his " manic delusional insanity " 
which, however, may include still more cases of another 
kind. 

The so strongly marked predominance of the female sex 
might moreover point to distant relationships with manic- 
depressive insanity. But perhaps the thought of hysteric 
admixture lies still nearer. The frequency of visionary 
experiences, the pompous, self-conscious behaviour, the 
nimbleness of speech, the susceptibility to influence, the 
tendency to make oneself conspicuous, indeed often remind 
one of the conduct of many a hysteric. One of my patients 
even had real hysteric seizures; in another .the disease 
apparently began in the form of a " magnetic sleep " with 
dreamy religious visions, which lasted almost without 
interruption for four months. Nevertheless, in view of the 
persistent delusions and hallucinations, of the slow develop- 
ment of the malady in advanced age, and of the evolution 
of psychic decline, there can naturally be no question of a 
real hysteric psychic disorder, quite apart from the fact that 
phenomena pointing in that direction come under observation 
only in a minority of the cases. 

Paraphrenia Confabulans. 

The next form, perhaps related to the previous one, 
confabulating paraphrenia, which certainly includes only a 
small number of cases, is distinguished by the dominant 
role which pseudo-memories play in it. The commencement 
appears sometimes to be a change in the conduct of the 
patients. They become quiet, reserved, irritable, withdraw 
themselves, brood a great deal, and then gradually come out 



3IO DEMENTIA PRECOX 

with a narration of very extraordinary experiences in the 
sense of delusions of persecution and exaltation. They feel 
themselves neglected ; they are persecuted, robbed, are to 
be poisoned. Everywhere there are suspicious signs ; stones 
are thrown, the windows are broken ; shots are fired. People 
slander, abuse and threaten them, cough at them, put out 
their tongues ; anarchists lie in wait for them ; a cash-box 
with bonds in it was stolen ; the King of Prussia will have 
them murdered ; they are being sold for immoral purposes, 
assaulted, beheaded. Many patients also hear voices, low 
whispering ; someone speaks in their ear and says what they 
themselves wished to say ; people are whispering secretly 
and laughing. 

Sometimes the persecution goes back into childhood. 
Already at school people aimed at ruining the patient. He 
was mocked by his relatives, roughly treated by his teacher, 
tempted to masturbation, was to be " ruined by bad habits " ; 
his mother wanted to poison him with an apple. Then he 
fell into the most remarkable dangers. The people, with 
whom he came in contact, were murderers and procurers, 
used abusive language, slaughtered people, buried the corpses 
or packed them up in boxes in order to sink them in water. 
It was announced to him that his turn would now also come ; 
people aimed at him, were going to slaughter him with a 
long knife, to blow him up into the air with an infernal 
machine ; five years ago at the railway station he saw a girl 
who was going to throw a bomb, and he prevented her just 
in time. All these experiences are narrated with the most 
exact description of the details as occurrences that have 
happened quite recently. A patient reported that he had 
dug up an amputated human arm, but then was compelled 
by his neighbour with a revolver in front of him to eternal 
silence ; nevertheless he gave information and an inquiry 
was really made. Another went into a brothel in order to 
convince himself whether cannibals lived there. People were 
aiming at his life, but he escaped, though later human flesh 
was put before him in a restaurant. The landlord betrayed 
himself, begged to be allowed to shoot him, failed however, 
and shot himself on that account. A female patient was 
criminally assaulted, and, because she knew too much, was 
going to be killed, when she was out walking, by a man 
who already had many murders on his conscience, and spoke 
quite openly about them ; finally, however, the matter was 
again postponed. 

Megalomania- — The confabulatory springs of megalo- 
mania flow almost still more abundantly. The patient is 



PARAPHRENIA 311 

descended from a royal family, is the illegitimate son of a 
prince, of King Ludwig and an Italian woman, was already 
in childhood abandoned to die of hunger. Officers and 
policemen saluted him ; he was called the wren (German, 
hedge-king). The clergyman made obeisance to him ; his 
school companions called him Prince. His fellow-workmen 
were the King of Spain and the Duke of Brunswick ; a girl, 
the daughter of the Emperor of Austria, said to him that he 
was the son of King Ludwig whom he resembled to such an 
extent that his real mother did not recognize him, and at a 
dance wished to enter into connection with him. The police- 
men on that account wore their beards like Ludwig IL He 
was also chosen to be Emperor but felt himself still too 
young for that. At the railway station the Emperor of 
Austria and the President of the French Republic met him ; 
the Grand Duke of Baden and the Emperor came disguised 
to him to sound him. He had listened to important political 
conversations and just at a time when important events were 
happening. When he was only sixteen or seventeen years 
old, it was imparted to him that he would get a house in 
Berlin and inherit the estates of Prince Schwarzenberg ; his 
mother spoke of it. At the post-office a letter containing 
money with an inheritance amounting to a million was shown 
to him and it was said that the sum was deposited at the 
bank. As a child he was taken to the Royal Palace and the 
room where he was born was shown to him ; later the King 
made himself known to him as his father by look and 
gesture. The patient met one of the two daughters of the 
King ; the older one promised to marry him. 

In this way the patients bring forward with the most 
profound conviction an enormous number of extraordinary 
stories absolutely in the form of personal experiences. They 
can describe exactly every glance, every look of the persons 
concerned ; they report every word, even though the events 
are referred back for decades, " This is all as distinct to me 
as if I saw it with my own eyes in front of me," declared 
a patient. Sometimes the often repeated descriptions fix 
themselves in the patients' minds in such a way that they 
are repeated almost in the same words. But, especially in 
the beginning, it is sometimes possible by questions to make 
the patients add fresh decorations, and they themselves 
continually produce additions which meantime have occurred 
to them. The patient, who had dug up the arm of the 
corpse, reported in the days following this narration, that 
his neighbour had buried something that smelt of corpses 
under a tree, that further a female neighbour had spoken of 



312 DEMENTIA PRECOX 

shambles in the cellar, that numerous individuals in the 
village disappeared, the patient's mother among them, that 
the dogs were fed with human flesh, that a woman of the 
neighbourhood threatened him with a revolver and announced 
that it would be his turn in a week ; lastly that one of his 
neighbours followed him in disguise when he fled into the 
town. 

The patients usually make light of the striking circum- 
stance, that their remarkable experiences were formerly not 
taken notice of by themselves. They had completely for- 
gotten it, have not thought any more about it, made no use 
of it, only later everything occurred to them again. A 
female patient said that she had first thought of it again 
when a whisper like a prompter had reminded her of every- 
thing ; she thought that her mother, who had foretold much 
of her fortune in life, had then taken away the thoughts of it 
from her ; " She understood that." 

The manner in which the patients in their confabulatory 
narrations draw conclusions, witnesses to the easy swiftness 
of their power of imagination. A patient alleged that he had 
heard French spoken, therefore the President of the French 
Republic was present ; a fellow-workman spoke of Brunswick, 
therefore he was the Duke of Brunswick. A female patient 
described how the King drew little round arches on his gar- 
ment with his finger ; obviously he wished by that to signify 
the rounded arch style of the royal palace in which she was 
born. Another said she had heard the wife of a guide in a 
picture-gallery say, " Money can be made in this rag-shop" ; 
from this it was clear to her that the valuable originals of the 
gallery had been secretly replaced by imitations. 

The part also which the patients ascribe to themselves in 
their pseudo-memories is very remarkable. Although accord- 
ing to their account it was said to them in so many words 
that they were to be killed, they did not take the slightest 
measures for defence or flight, continued to associate for 
weeks with people who let themselves be known as terrible 
robbers who also committed murder. The most exciting 
information about their royal descent, their gigantic inherit- 
ance, their brilliant prospects of marriage, they have taken, as 
they allege, with the greatest equanimity and quickly for- 
gotten again, without troubling themselves further about the 
matter, till it by chance occurred to them again. Pointing 
out all these impossibilities, however, usually makes little 
impression on the patients ; they admit, perhaps temporarily, 
that it was " all nonsense," but later again come back to it. 

The content of the pseudo-memories is by no means 



PARAPHRENIA 



o^j 



always limited to the actual delusions of persecution and 
exaltation ; it is frequently connected also with more remote 
personal experiences and everyday events. It occurred to a 
patient that he had formerly seen \\\s fiancie, who he thought 
was very rich, and also her father, in an institution ; at that 
time touching stories were told him about the sad fortunes of 
the real father and the abominable crimes of the foster-father. 
A female patient described- with the most absolute certainty 
a great many occurrences which incriminated her husband's 
superior in the most serious way and which were blindly 
believed by the husband himself But further, she reported 
most extraordinary experiences, dating about twenty years 
back, with Prince Eulenberg, with Richard Wagner, and with 
King Ludwig, in such a clear, lively, detailed way that she 
was called as a witness in a lawsuit. Another narrated that 
people signified to her, by closing their eyes and nodding 
their heads, that King Ludwig had sat by the water and had 
fallen forward. 

Very frequently pseudo-memories are also connected with 
the surroundings of the moment. To the patients everything 
appears familiar; they have already been once before in the 
rooms of the institution ; the house and everything, that 
happens to them, have already been described to them 
previously ; it is a hotel in which they lived seven to eight 
years ago with the children ; they remember the view, the 
service in church ; it gradually comes to them that they have 
seen all that before. The physician also is known to them. 
" Don't look so innocent, as if you had nothing to do with it," 
said a female patient. The nurses, the other patients, are old 
acquaintances, are using false names. " Don't impose upon 
me," replied a female patient to our objections. The things 
which others are wearing belong to them ; the furniture 
comes from their house. The same persecutors return but in 
changing disguise. A female patient asserted that the role 
of her husband was played by different people, that he was 
sometimes smaller, sometimes bigger, sometimes stouter, 
sometimes thinner. The children also have been exchanged, 
are not hers, are from the foundling hospital. At a visit she 
did not acknowledge her husband, but tolerated his attentions. 

Besides the morbid ideas which stand in relation to the 
pseudo-memories there are as a rule other delusions of various 
kinds. The patient is to be deprived of his rights, is 
surrounded by detectives, is given poison. Visitors are 
confined in the cellar ; the whole house was cleared out ; a 
revolution is breaking out ; Emperor and King are over- 
thrown ; his wife has murdered the children. The patient 



314 DEMENTIA PR.ECOX 

believes that he is surrounded by murderers, is being tortured. 
He rs related to Bismarck and the Emperor William, receives 
a message, that he is to make an aristocratic marriage. His 
mother is not dead, has inherited a house from Rothschild. 
Someone tells him in his ear that he is Christ, the son of God, 
that he will be more blessed than all the others. He has the 
stigmata, is the young man at Nain ; the ship of the world 
was about to perish ; then one has come to save it. 

The Consciousness of the patients is in all their 
nonsensical delusions permanently untroubled. They are 
quiet, perceive without difficulty, give clear and connected 
information, behave themselves reasonably. So far as their 
delusion does not come into question they are usually 
perfectly clear even about their surroundings and their 
position, yet the occurrences going on round them often 
appear to them mysterious and incomprehensible. " I could 
not e.vplain it all to myself, had nothing but riddles before 
me and would have soon become insane," declared a patient. 

Mood in spite of the ideas of persecution is as a rule 
cheerful, exalted, " quite happy," yet temporarily anxious or 
irritable. The patients are usually very accessible, loquacious, 
verbose, desultory, with a tendency sometimes to silly plays 
on words. They are constantly bringing to light fresh details 
of their delusional recollections with great vivacity ; they 
defend their ideas with vigour and ability, let themselves also 
be guided in their activity by them. They go to the police- 
office to get information there about their affairs, give 
information to the public prosecutor, try to withdraw their 
money from the bank. 

The Course of the disease seems to be progressive. For 
the most part the luxuriant growth of pseudo-memories 
forms only a comparatively short period of the disease, even 
though the delusional inventions are retained for a consider- 
able time, repeated, and perhaps still somewhat further 
adorned. In a year's time they may have completely paled ; 
the patients do not wish to hear anything more about them, 
do not know anything more about the stories, are evasive ; 
*' That is a private matter." At the same time the delusions 
become more nonsensical, more incoherent ; mood becomes 
irritable, morose or indifferent, so that no doubt exists as to 
the development of a psychic decline. Unfortunately of the 
cases which were at my disposal only a single one hitherto 
was observed longer than a decade, so that I am not able to 
make any more precise statements about the last fate of 
these patients. 

The extremely remarkable morbid state described here 



PARAPHRENIA ^ 315 

is not frequent ; in nearly thirty-five years I have scarcely 
seen more than a dozen marked cases. Both sexes appear 
to be equally represented ; according to age my patients 
were distributed fairly evenly among the three decades from 
the twentieth to the fiftieth year ; they were therefore on the 
average somewhat younger than the patients discussed 
previously. I have no special experiences to bring forward 
in regard to the causes of the disease, except that of several 
patients it was stated that they had always been quiet and 
introspective. 

Delimitation. — As the characterization of the clinical 
picture essentially rests on a single clinical symptom, 
certainly very striking, but one which in less marked form 
occurs also in other forms of disease, its peculiar place must 
not be considered as on sure foundations. Nitsche has 
published one of our cases in agreement with myself as 
chronic mania. Meanwhile, after more exact investigation 
of a considerable number of paranoid cases, I incline to the 
view that it is to this group that it belongs. Many circum- 
stances, the comparatively early commencement, and the 
psychic involution, certainly as a rule distinct after some 
years, would point to a relationship with dementia prcecox, 
especially with those forms which have been called idiopathic 
paranoia. As long, however, as the issues of the group here 
discussed and their relations to dementia prascox are not 
better cleared up by more extended series of observations, I 
should like to assign to it a place by itself This view is in 
any case supported by the complete absence of ideas of 
bodily influence and of volitional disorders, unless the 
occasional making of faces and stiff repellent conduct are to 
be regarded as such. 

Paraphrenia Phantastica. 

A last group of cases to be discussed in this place, like- 
wise not very comprehensive, I should like to call paraphrenia 
(dementia) phantastica; here it is a case of luxuriant growth 
of highly extraordinary, disconnected, changing delusions. It is 
covered in the essentials by dementia paranoides formerly 
described by me ; as meanwhile this term has been in general 
frequently used for the delusional forms of dementia praecox, 
I consider that for the prevention of misunderstanding it is 
expedient to take a new name. The disease appears often 
to begin with ill-humour. The patient becomes enervated, 
spiritless, depressed, quiet, anxious, has no right vitality, 
thinks also, perhaps, of suicide. 



3i6 DEMENTIA PRyECOX 

Ideas of Persecution then gradually come to the surface. 
The patient notices that he is looked at in a certain way, 
that the people in the house make fun of him, carry on' 
spiteful conversations, seek after his life, listen at the door, 
do not leave him any peace ; it is a baiting of him. He 
stands by the hour under police supervision, is denounced, is 
made answerable for everything, is to be castrated, to be 
punished because of robbery with murder and theft ; he is a 
subject of study, and must do penance in experiments ; 
people wish to take his property from him. His letters are 
not dispatched ; in the newspapers he is roundly abused ; a 
flash of light is sent through the room by electricity ; in his 
absence the neighbours force their way into his house, take 
away clothes, spoil the things ; they are a gang of criminals. 
Officials appear with falsified certificates and under false 
names; his wife is changed. In his food the patient finds 
saliva, f?eces, human blood ; he is stupefied with chloroform 
and sulphur ; everything is drenched with sulphuric acid, is 
full of arsenic and phosphorus ; his bed stinks, contains 
serpents 

Hallucinations of Hearing also invariably appear now. 
The patient hears whispering, chirping, wicked slander, whis- 
pering voices, spirit voices, telephone voices from the ceiling, 
" voices in public and when people meet on the street." 
People persecute him with the telephone apparatus ; reproach 
him with his faults (" wax manufacturer " !), call to him, inform 
him that his family is dead, that he is pardoned. The magis- 
trate and the police, the Emperor and princesses speak ; his 
sister weeps subterraneously. Invisible people are present in 
the room and speak ; out of the cushions whispering voices 
make their way from the devil and his light-bearers ; his 
guardian angel speaks ; Jesus murmurs; it is the " magic of 
revelation " ; the spirit of hearing is sitting in his ear. 
Animals can also talk ; " I have spiritual ears, when the flies 
speak to me," declared a female patient. The patient carries 
on conversations with the voices, converses with the ministers 
in Berlin, telephones with God. The voices accuse him, 
praise and threaten him, dictate to him, read aloud what is in 
his letters and in the newspapers, know his thoughts, tell 
them to him ; a compulsory examination of his thoughts is 
taking place. They also make remarks about what he does. 
" Now she feels it," is said, when anything is painful ; " Now 
he is speaking French so that he may not be understood"; 
'By God, she says everything; everything comes up," a 
murderer calls out. A female patient heard voices which 
were in constant contradiction with her thoughts. " They 



PARAPHRENIA 317 

are strange spirits which speak out of me," declared a patient. 
Another had a feehng as if he repeated what he heard with 
the breath of his mouth ; he was always afraid to do harm by 
a wrong word. A third distinguished between street-voices, 
conversation-voices and whispering voices ; the last origin- 
ate from people "generated inside," contained in his interior; 
with the first it is as if a whole street would appear ; " The 
voices are let loose, meet with people, are established firmly 
in the ears." 

Hallucinations of Sight on the other hand usually play 
only a small part. The patients see the light from the 
electric current, dark shadows which go out, the Saviour, 
the heavenly Father, angels, dust-insects in the air, bodies 
hovering in the air, figures, which change their form and 
size ; people are changed by magic. 

* Dysaesthesiae and Influence. — On the other hand 
common sensation and especially the delusion of personal 
influence, which is connected with it, takes up a very large 
space in the morbid picture. The patients complain of pains 
and dyscesthesia; of all kinds ; they are tortured, flogged, 
dishonoured ; they feel shooting pains in leg, head, and 
breast, burning in the urethra, formication at the penis. 
People give them colic with electrical apparatus ; they are 
pushed about, they get injections in the skin, are stupefied. 
Their testicles are electrified ; their voice is altered ; their 
whole body is changed ; their thoughts, their memory, are 
taken by spiritualistic arts and roguery, witchcraft and magic 
agencies, by invisible persecutors " remaining under cover." 
A patient felt pinching, pricking, pressing, lightning in his 
brain ; his heart was rubbed down with a curry-comb, his 
bowpls were rhythmically contracted ; another thought that 
he had instruments in his body. At night the patient is 
hypnotized, dragged away, made to do ugly things with 
females. A female patient had the feeling as if someone 
were always about her ; at night someone stood behind her 
and confused her thoughts ; she had to do all sorts of 
indifferent things, had to cut open her arteries, was abused 
sexually, even by the mouth. " People have such an influence 
on me that it is terrible," complained a patient ; " I cannot 
write unless they wish ; they have an influence on all parts 
of my body." 

In isolated cases these sensations and ideas acquire quite 
prodigious forms. The patient was made sterile, has only 
a few small stones in his scrotum ; his bones are being 
broken ; his liver, spleen, lungs, bowels, the root of his penis, 
are torn out ; his marrow is sucked out by devilish instru- 



3i8 DEMENTIA PR/ECOX 

merits, his sexual parts are drunk out, his breast-bone is 
exchanged, his clavicle is cut through four times ; his head 
has been broken in pieces nineteen times and the parts torn 
out have been replaced by new ones. His body is being 
melted down ; he feels the circular saw in his head ; his body 
is being torn asunder; his legs are being taken oft" by the 
railway ; his arms are separated by a great distance so that 
he feels the intervening space ; his eyes stand far out from 
his head, are hanging by bloody ct>rds a yard long. All 
machines and impulses pull at him ; his organs are laid 
against the bulb of the electric light ; the mouth-harmonica 
is sucked fast to his mouth ; he feels himself harnessed to a 
kettle. " The direct mechanism of the machine is the point 
round which life, so to speak, the organism twines itself up ; 
I don't know how that is, but the mechanism pursues me 
for vengeance," said a patient. The voices also specially 
influenced him. " This talk that strikes a man in the street, 
reduces him to a state in which one cannot defend himself; 
they lie in wait for him, drive him to actions of violence," 
he declared ; " one may fall down because of it. This attacks 
men in their innermost parts, excites them terribly, comes 
like lightning, and stirs up even the natural and actual 
circumstances in which one finds oneself at the moment." 
Another patient thought that he was being attacked by 
" volitional thoughts," invisible strange people ; when he read 
or wrote, wrong letters and words were substituted. A third 
asserted that he was chained to the whole world. 

But the most remarkable thing is that the patient feels 
and sees other people slip into his body. Individuals dis- 
appear in him, lay themselves " in his form " ; a whole crowd 
of people can be dragged along by him. A patient 
noticed that a whole motor-car drove into him ; the steering- 
wheel stood out at his ears. Freemasons are in him ; his 
father is in his right calf; the Emperor Frederick is in his 
body in order to be saved. His whole body is full ; people 
who are not themselves, wholly torn to pieces bodily, head 
here, spirit there, come flying out of the air ; there is a going 
in and out like a dovecot. The patient consists of thirteen 
individuals ; eight females are inside him. " F'ive hundred 
females were in me and outside me," declared a patient. 
Another said, " I appear to myself like an empty room, which 
is constantly inhabited by new tenants. What use is it that 
I drive them out ? They, are so shameless and come again." 

Sometimes the troubles are of markedly sexual nature. A 
model of the patient has been made ; as soon as the sexual 
parts of it are touched, he is stimulated and tempted to sin. 



PARAPHRENIA 319 

Aristocratic persons slip in and out of his penis ; a princess 
sits in his penis ; empresses and queens beg to be allowed to 
play with it, and ask, " May I ? May I ? " A patient asserted 
that he was used for breeding ; people were bred into him, 
developed in him. He felt that he was being copulated 
through the nose, the larynx, through wounds into which 
people were passing. A female sexual organ developed 
on his eye, while the rest of the body floated in the air in 
front of him ; also in a wound in his penis a girl nine years 
old played with his sexual organs. These girls spoke through 
his organs without his wishing it ; he was accused of having 
done wrong to them, and thought that was perhaps done by 
other men. A patient felt himself pregnant, called himself 
Francisca, wished to be relieved of his genitals and to be 
placed in the Maternity Hospital, and he wanted to become 
the most beautiful woman on earth. 

Scarcely less incomprehensible than these ideas of in- 
fluence and of being possessed are the other delusions 
which are produced by the patients in almost inexhaustible 
abundance. They can partly be classified as delusions of 
exaltation or of persecution ; but partly it is a case of wholly 
senseless and aimless playing with the most extraordinary 
and sudden ideas. Their relations are being cut to pieces ; 
their father has throttled his two sons ; in the storehouse 
200 people are daily slaughtered. In the house there is a 
machine for beheading people ; many have alreddy offered 
up their lives ; poisons and soporifics are being sold to 
landlords for giving to their guests. An international enter- 
prise exists for " getting rid of people " by means of lifts in 
hotels, which unexpectedly go down into subterranean vaults. 
There a sausage-machine stands for the many slaughtered 
people ; already during six years milliards of people have 
been daily murdered ; whole towns are empty ; it is a 
devilish crime. Everyone is eating human flesh ; the food 
contains human blood and female genitals ; from bones and 
brain cheese is made ; Prussians and parsons are behind it 
all ; everything happens by the order of the master of the 
lodge for penance. Everywhere there are electric wires ; 
the fellow - patients are procurers; disguised enemies are 
there; they have taken the complexion, the capacities, speech 
from other people by magic ; the Sovereign has shot himself, 
is a robber who commits murder ; the end of the world, 
the fulfilment of the Revelation is at hand. The patient is 
by a bull of excommunication enchanted into a horse for 
his whole life long ; he has insect spirits in his body ; he 
has often been stabbed and shot ; he has three hearts, is 



320 DEMENTIA PR.ECOX 

now without heart and lungs, is already dead, cannot think 
any more, has female genitals. 

On the other hand the patient is descended from noble 
parents, is the stolen child of the Queen-Dowager, has been 
taken from a golden cradle to a shoemaker and his wife, is 
the son of Prince Charles, Duke of Habsburg, according to 
rank Emperor of Berlin, President of the Republic of Hesse. 
Other patients are, he who is to come. Emperor and God, 
first and last man, the first prince from the beginning of the 
world, a supernatural being, a fairy prince. Royal Highness, 
Majesty of Heaven and of Earth, Regent of the apes, 
Emperor of Austria, Napoleon, appointed to be King of 
Bavaria, Emperor of the world and owner of the whole 
world. , The whole of Europe belongs to the patient ; he 
has ruled over town and country from birth. A patient 
declared that the old Emperor, the Emperor Frederick and 
the present Emperor were united in him ; inside another 
patient Prince Charles and the Emperor Frederick had been 
since he was five years old ; " Together we are called 
Charles F'rederick," he said. Women are the Madonna of 
Lourdes, Grand Duchess by birth, the most highly-placed 
woman on earth, stolen from Coburg, the second Queen 
Luise by her "high, high, high, high father," goddess of 
hunting, the highest and noblest that exists. Majesty Clara, 
Regent of the House, capitalist of disease ; they will give 
birth at Christmas to a Child Jesus, want to marry a high 
officer ; a female patient declared that she had many children 
by Saint Theresa. 

By the grace of God the patient has become infinitely 
rich, will receive for his piece of ground an untold price, is 
getting millions of money and jewels from the Emperor of 
Austria and from an American railway king, demands his 
milliards, possesses a kingdom of millions, thousands of 
square miles in Mars, Neptune, and Venus, wants to go to 
his palace, has inherited everything here, gets for each day 
100,000 marks damages, receives cash remittances from all 
quarters, which are embezzled. He can make bread from 
stones, has studied the original language, has a knowledge of 
important state secrets ; he is to marry a princess, is secretly 
married to six majesties. Prince Bismarck is coming ; the 
King of the Netherlands will set him free ; a prince is waiting 
in the next room ; the Emperor Francis Joseph is there, who 
has married the patient's sister. He is nourished by the 
earth magnet, fed by the Holy Ghost who tells 'him every- 
thing, is in him, draws off the poison ; he takes copies of the 
most beautiful pictures by golden wires with magnetic print- 



PARAPHRENIA 



321 



ing and electricity ; he possesses the African method of h'fe 
so that he cannot die, has grace, is in the service of the 
Godhead, receives revelations from the spiritualists about 
the approach of the end of the world ; words of God flow 
from his mouth ; God lives in his body. 

The delineation of the high-flown exalted ideas leads 
sometimes to an extraordinary expenditure of superlatives 




^^^^^P^^ ^ 



Specimen of Writing 7. Paraphrenia phantastica. x f , 

in which the patients try to describe their immeasurable 
superiority and suffering. An idea is given of it by the 
following extract from one of the innumerable documents 
endlessly repeated in a similar way with which a female 
patient furnished us. I add from them also a specimen 
of writing in which the effort is made in its large, 
pretentious features to do justice to the highly strained self- 
consciousness. 

" I have here the Highest of all, the most Immeasurable of all, the 
most Sublime of all the most Colossal of all the most Boundless of all 



322 DEMENTIA PRECOX 

the most Unlimited of all the most Distinguished of all only Highest of 
all only most Immeasurable of all only most Sublime of all only most 
Colossal of all only most Unlimited of all (so on for six folio pages), born 
the being possessing the most Devoted most Loving most Passionate 
Embracing all Embracing all more than all hottest Hottest of all 
Reverence Love Thankfulness, Devotions, Passions, Adorations, Adora- 
tion. . . I was, am and remain this, a most Excellent of all a Greatest of 
all Unique thing of immortality in the most Many-sided involuted 
manner kind of accomplishment ! . . . Have been almost three years in 
the most terrible way the victim of a most bestial most dreadful band of 
murderers and robbers, by which I was slaughtered to the most dreadful 
cripple with the pains of death murdered and robbed am besides was 
murdered in comparison with my former most perfect beauty in a most 
dreadful ugliness, was am murdered and robbed it reaches back to my 
birth 1 suffered suffer as continuous victim of all bands of murderers and 
robbers on the earth the most boundless murders murders with robbery 
murders of honour I was am remain the most Excellent of all most 
Versatile most Sublime Best most Immortal being was most enormously 
rich most Magnificent Monarch of Many States. . . ." 

The capital letters should be noticed, the absence of 
marks of punctuation, the anxiety by repetition, by using 
stronger terms, by the conjunction of past and present to 
attain to the greatest possible impressiveness, lastly in the 
specimen of writing the singular mannerism of writing single 
letters (here the m) twice in different ways. 

Pseudo-memories. — Frequently the delusions clothe 
themselves in the form of pseudo-memories. The patient 
had from the beginning a foreboding soul ; as a child he was 
stolen, abused, had to endure great struggles ; he made 
journeys to China and to the North Pole, was appointed 
King of Bavaria in the Parliament nine years ago. He was 
fished up from the River Amazon, rubbed together from 
saliva, made small by plaster of Paris dressings, hounded for 
twenty-five years through the animal kingdom. People 
wanted to strangle him, behead him, poison him, throw him 
from the tower, kill him by electricity. He was Christ and 
Paris, Eve, Moses, Alexander the Great, Cctsar, Victoria, 
Mary Stewart, the Maid of Orleans, Eugenie, Napoleon, was 
killed several times, pierced by fifty bullets and thousands of 
needles, already as a boy poisoned with cantharides, was to 
have been misled to onanism ; he created the first j^eople, 
has studied medicine, was lecturer at a university, changed 
every two hundred years between studying and ruling, was 
to direct the whole world in seven years. He has eaten a bit 
of the archbishop, carried on a conversation with the devil of 
Zurich ; he was also the serpent of Paradise ; he is always 
being born again, has lived already a dozen times, has 
founded the town of Jerusalem, has deposed all dynasties, 
appointed stadholders instead, spends the night in the under- 



J 

^ 



PARAPHRENIA 323 

world, fights fearful battles day after day with the enemies 
of the country. He was professor to the Queen of England, 
saw there a machine for manufacturing children, worked 
along with the Hereditary Grand Duke as joiner and stone- 
mason, was in 1895 in the assembly of spirits, was also the 
huntsman who shot the girl in Switzerland. An inward 
voice tells him everything that is going to happen. The 
institution has already been built ninety-seven times ; the 
fathers also have done penance here. 

Sometimes delusions of this kind are connected with 
every idea aroused by chance ; the patient has himself 
experienced every event in history, which is mentioned in 
conversation ; he was the Emperor William, Bismarck, 
Napoleon I. and HI., Alexander III., all in one person ; if the 
conversation is about cloth-mills, he declares that he himself 
possesses large cloth-mills in all the towns of Germany; he 
tells the physician of the most marvellous operations which 
he has carried out as surgeon ; he already knows all the 
newly admitted patients, as he knew them previously ; he 
can narrate extraordinary experiences with them. A patient 
discovered, when out walking, lions, buried cities, gold and 
silver mines. 

All kinds of other confabulations, which do not bear the 
form of personal experiences are probably nearly related 
to pseudo-memories. A female patient narrated the most 
nonsensical stories from the past history of her fellow- 
patients ; a patient asserted that Christ had been crucified 
in Augsburg ; the battle of Hermann did not take place 
in the Teutoburger Forest ; Bismarck was still alive. 
Another related that Napoleon, his brother, had been 
beheaded the previous winter in France. Here belong 
also the ideas of descent which frequently come to the 
surface. A female patient thought that the seed of wrecked 
human beings got out of the sea-water into sharks, there 
become " rochus," and then again human beings ; from the 
union of women and animals there arise half-men ("Gromen"); 
she spoke of " seed-sisters and brothers," who must marry 
each other. Another declared that her mother was descended 
from the dove of Zacharias; the first bride of Christ was 
an Indian girl, Lararuk ; she herself was the second, and 
overshadowed by Him she became the mother of the Christ- 
child at Munich. Another time she narrated that 4000 
years ago Christ had married Lucinda, and she was descended 
from this union ; the Gospel was- wrong ; it was beneath 
the dignity of a God to let Himself be begotten and 
crucified. Further she was a grand-daughter of Napoleon 



324 DEMENTIA PRECOX 

who married her grandmother in the cathedral at Spires ; 
he was accompanied everywhere by Christ. The heir to 
the throne was descended from a peasant wench, his wife 
from a bishop, who had 100,000 children. 

A patient elaborated a comprehensive narrative of 
historical connections, freely invented, in which he declared 
all royal families to be spurious, all statements of history to 
be falsified ; he had made many investigations, had taken a 
great deal from American newspapers, and he possessed 
excellent intellectual powers. Accordingly the patient was 
descended from the Duke of Reichsstadt who was a female 
and the daughter of the real Napoleon and of the daughter 
of the real Frederick II.; the former was a chemist in 
Baireuth and lived to be 130 years old; the latter was 
a hermaphrodite and was deposed. William I. also was a 
hermaphrodite, and was superseded by a master shoemaker ; 
the Emperor Frederick's real name was Frederick Geier 
(Vulture), and he came from Niirnberg. Ludwig II. con- 
sisted of three persons; the first was a sodomite who com- 
mitted rape and murder and was later a clergyman in the 
Allgau, the second was the son of a day-labourer, the brother 
of Clara Ziegler, and was still living in poor circumstances; 
the third is a hermaphrodite and became an actor. The 
Habsburgs are a baker's family from Eriangen ; the 
Hohenzollerns are derived from Hungarian Jewish circles, 
the Russian Emperor from the Jesuit family of the Medici 
in Baireuth. The patient declared that he himself was 
the last scion of all these and of many other princely 
families. 

As already appears from the foregoing description, it is 
here everywhere a case not of connected, mentally elaborated 
circles of ideas, but of variegated, often-changing sudden 
ideas of a moment, some of which are certainly retained 
for a time, but which mostly are replaced by ever new 
and just as transient creations. A patient at repeated 
interviews called himself Graf Eberstein, Monarch on the 
Prussian throne. Lord of the Dead, a new God as Prussian 
general. Prince William in uniform, last professor, soldier, 
American gentleman, guardian of the institutron, double 
District Medical Officer. 

During the extraordinary delusions described the patients 
may be completely sensible, clear and reasonable in their 
behaviour, yet they often mistake in a delusional way their 
surroundings and individuals ; they are in their kingdom, in 
the penitentiary, in the devil's den of murderers, in the den 
of rape, murder, whoredom and robbery ; they see round them 



PARAPHRENIA 325 

acquaintances, highly placed persons, viragoes, enemies ; the 
physician is Charlemagne. Sometimes the patients have 
a certain feeling of the change which has taken place in 
them, but no clear understanding of its significance. A patient, 
who was usually extremely irritable and violent, had interven- 
ing periods in which he was accessible and exaggeratedly 
grateful, but without real insight into the disease ; he 
thought then that he was " as if awakened from a long sleep," 
to be after some time again dominated by the old delusions. 

Mood is as a rule somewhat exalted or indifferent, but 
sometimes also gloomy, strained, and inclined to violence. In 
conversations of any length the patients fall into a certain 
excitement. They usually bring forward their delusions 
with fluency and prolixity, often in a very confused and 
desultory manner, while they are able to give information 
about remote questions clearly and to the point. Their con- 
duct is frequently somewhat affected ; occasionally grimacing 
is observed. Their speech is usually interspersed with 
peculiar turns of expression, but specially neologisms. A 
patient spoke of the " alphathunderbook," the compendium 
from the court law or university lexicon, called himself the 
" cyklesteraksander and brain inventor"; Aksander was a 
Christ-brain, Cyklester a penitential body, Rader someone 
who speaks out of one without one noticing it. A female 
patient declared that princes had as dynasty people (suite), 
"feds," dukes, " fesochs," emperors and kings, "fusaltos"; the 
world was a "cultar," a magnet, which forces vegetation. 
Her parents drove into the " Erdall," were merely killed ; her 
ancestor was " Doreal " with the Emperor of Iceland, which 
again consisted of Rumenien, Ostrumenien, Jeromin and 
Morasto ; her grandfather went with Emperors and Kings 
into the Erdterail, in order to hold Tyram or Tore. Another 
female patient thought that she had been dragged in as a 
poodle and suction-pump. Many sentences may be quite 
incomprehensible. " That is a great family word, that will 
never end, without war and deeds," declared a female patient ; 
she had as a child experienced the most wonderful things, 
the virgin icxx) and no night; "that is beautiful and pay- 
able." 

Silly plays on words also, nonsensical rhymes and 
witticisms are not infrequent. A female patient said that she 
was Socrates, should do "so grad'es"; a patient connected 
" Chamisso — Scham is so," " Wahrheit — wahrer Heid," 
" Doktor — Dogg-Tor " ; another spoke of Leipzig " the town 
of the sacred masses and of the sacred religions, of the sacred 
legions." A third thought that fractures could be cured by 



326 DEMENTIA PRv^COX 

introducing the new calender and abolishing fractional 
arithmetic ; he wanted by the abolition of prostitution to turn 
" Klagenfurt" into " Ehrenfurt." In spite of such occasional 
nonsensical interpolations the patients can still usually make 
themselves quite intelligible, especially if the matter in hand 
has not to do with their delusions ; they sometimes write 
faultless letters. 

An example of the peculiar utterances of such patients is 
given in the following transcript : — 

" You will probably know what that means to be an immortalized 
spirit, although I am only a simple beer-brewer and had to go through 
that if anyone raises himself from a low rank to the nobility. It was 
certainly from birth Count Eberstein, but first by the head-disease and 
the strained memory the accession has resulted, so that he is Frederick 
William III. from then onward the fourth, which therefore has direct 
relation with William I. and Frederick III. That means the immortalized 
and that means that he is not it now for the rabble ; we know well why 
the pictures and flags have been waved to the right, that means the right 
one will come. . . I know that I am mad ; that means that I must suffer 
by head-disease and by memory voices, but then it is also possible that a 
common fellow comes to high station ; that will mean much, if one is to 
have memory for the general staff and the government. . . You have not 
the least idea how much goes on in my head ; I often think it must burst. 
You don't know at all what happens to me at night ; I frequent in fact 
the most glorious marble halls at night ; then I am many miles away. 
Last night I had 20,000 marks in my hands ; here there are only twenty 
and ten mark pieces, but there there are also thirty mark pieces ; that was 
not in dream, but by day ; there was on the pieces the President of America 
from Hamburg. Indeed you don't know at all what intercourse I have at 
night, the expanding pictures ; then I am indeed in glorious, wholly 
unknown towns, where I never was before, or, as last night, in glorious 
ships on the sea. In this world-globe, which I frequent at night, it is 
quite different from here ; it is perhaps a continent behind the moon. I 
am far away outside, though I am in the asylum. In December, January 
I have eaten cherries there, when here in winter-time there are certainly 
none at all. . . For eighteen and a half months already I have been 
William I.; but through the length of time I have obtained the double 
order of the crown ; at that time I was already as much as the most 
mighty King on earth. If Jesus Christ had been let go free and not 
innocently crucified, perhaps it would have happened to him as to me, by 
the head-disease throughout become equal with his father. . . ." 

On the one hand the mental activity of the patient 
appears here in the vivacity of the descriptions, on the 
other hand there is occasional derailment into quite incom- 
prehensible turns of expression and trains of thought. 
Further, the fabulous exalted ideas come to the front with 
wonderful nocturnal experiences probably pointing to pseudo- 
memories, lastly, there is the morbid feeling which shines 
through and which is brought into singular relations to the 
exalted ideas. 



PARAPHRENIA 327 

The Course of the morbid form described here is pro- 
gressive. In time the utterances of the patients usually 
become i^radually more confused and more disconnected. 
The neologisms and queer turns of expression often greatly 
prevail ; the behaviour also often becomes peculiar. The 
emotions become duller with rapid explosive outbursts of 
violence and transient states of excitement. Many patients 
remain permanently capable of M'ork ; others are limited to 
long-winded speeches and the composition of comprehensive, 
scarcely comprehensible documents. The rapidity with 
which this dementia develops appears to be very varying. 
Sometimes it is already distinctly marked at the end of 
four or five years ; I also know, however, cases in which 
after one and even after several decades, in spite of the 
most extraordinary delusions, there could be no talk at all 
of real confusion or at least not of a higher degree of 
psychic weakness. 

Among my patients the male sex preponderated with 
60 to 70 per cent. ; almost the half of the patients were in 
age between thirty and forty years, a quarter in each of the 
decades below and above that. In one case there w^as at 
the age of twenty-one years a state of depression which 
gradually disappeared again, and which was followed between 
forty and fifty by the development of the delusional attack. 
Some of my patients were described as gifted, vivacious, but 
fantastic, others as frivolous, stubborn, self-willed ; several of 
them had a criminal career behind them and fell ill in prison. 

Delimitation. — In this form also it must remain doubtful 
whether it corresponds to an independent morbid process. 
It cannot be denied that there exist many similarities with 
the paranoid forms of dementia pr(Zcox, especially with the 
cases which issue in drivelling dementia ; also the falling ill 
in prison which was repeatedly observed, could be advanced 
for this view. Nevertheless, the clinical picture is so peculiar 
that a separate description of it might in the meantime be 
justified, even though it should turn out later that gradual 
transitions to the forms named exist. In any case it is 
noteworthy that here, in comparison with the so unusually 
severe disorders of intellect, the injury to volition by the 
morbid process is wholly in the background, if we do not 
regard a certain mannerism and the disorders of speech. In 
connection with this it must be emphasized that the mental 
activity of the patients as a rule remains strikingly well 
preserved. They may appear in their conversation extra- 
ordinarily confused, but at the same time be vivacious and 
accessible, and because of the absence of volitional disorders 



328 DEMENTIA PRyECOX 

act quite reasonably. In this connection they recall to mind 
the cases of confusion of speech formerly described, from 
which, however, they are to be distinguished by the delusions 
which are here so extremely luxuriant. It might be con- 
ceivable that a nearer relation existed between these two 
forms or at least between parts of them, as at present we 
are not yet able to judge whether the peculiar delusions 
observed in this form may or may not be regarded as an 
essential morbid symptom. Naturally the possibility must 
also be remembered that the cases brought together here 
under this point of view are perhaps among themselves by 
no means of the same kind. 

The Treatment of the morbid forms discussed in this 
section has essentially to keep in view only the timely care 
of the patients who are almost always in need of institutional 
life, and further the preservation, as far as possible, of their 
psychic personality by suitable occupation. 



INDEX. 



Adolescent insanity, 224 

Age, 209, 224 

Akataphasia, 70 

Alcohol, 92, 335, 241, 259, 301 

Ambitendency, 50 

Ambivalence, 50, 248 

Amentia, 275 

Aphasia, 83 

Apperceptive dementia, 76 

Association, 19 

Association experiments, 19, 263 

Ataxia of the feelings, 35 

Attention, 5 

Autism, 49, 52, 248 

Auto-echolalia, 43 

Auto-echopraxis, 43 

Auto-intoxication, 244 

Automatic obedience, 37, 107, 142 

Baths, 279 
Blood, 85 
Blood-pressure, 84 
Bodily symptoms, 77, 207 

Calculation tests, 24 

Castration, 278 

Catalepsy, 141 

Catatonia, 42, 79, 80, 86, 116, 131, 

145, 254, 257, 261, 266, 267 
Causes, 224 
— External, 240 
Cerebro-spinal fluid, 87 
Classification, 89 
Clinical forms, 89 
Complexes, 35. 5i. 9i. 246 
Conduct, 96, 115, 119, 126, 136, 173, 

191, 202 
Consciousness, 17 
Constraint of movement, 40, 148 
thought, 22 

Degeneration, 235 
Delimitation, 252 



"D^lire chronique," 253, 284 
Delusions, 26, 94, 112, 118, 124, 133, 

154, 268, 284, 302, 310, 315 
Dementia, Agitated, 116, 122 

— Apperceptive, 76 

— Circular, 117 

— Confusional speech, 177, 256, 328 

— Delusional depressive, 109 

— Drivelling, 197, 206 

— Dull, 199, 206 

— Manneristic, 201, 206 

— Negativistic, 203 

— Paranoid gravis, 154, 252 
mitis, 165, 252, 256 

— Periodic, 129, 256 

— Silly, 94, 200 

— Simple depressive, 103, 208 

— Simplex, 90 
Derailments in speech, 65, 70 

train of thought, 72 

Diagnosis, 257 
Disintegration, 76 
Dissimulation, 273 
Drawing, 59 

Dreams, 67, 69, 247, 250 
Dyssesthesise, 167, 272, 317 

Echolalia, 39, 56, 142 
Echopraxis, 39, 142 
Electricity, reaction to, 79 
Emotion, 32, 74, 96, 270 
Endogenous dementias, i 
Engrafted hebephrenia, 225, 260 
Epilepsy, 274 
Ergodialeipsis, 47 
Ergographic experiments, 79 
Evasion, 21 

Flexibility, waxy, 38, 115 

Flow of talk, 56 

" Folic morale," 259 

Frequency, 224 ; 

Freud, 91, 246, 249 



329 



330 



INDEX 



Genkrai. conditions of life, 231 
General psychic clinical picture, 74 
Germ, injury to the, 234 
Gibberish, 68 

Hallucinations, 7, 103, 109, 117, 
122, 13s, 1 55, 166, 193, 271, 286, 
304, 316 

Hallucinatory verbigeration, 1 1 

Hallucinatory weakmindedness, 192 

Hebephrenia, 89, 94, 224 

Hebephrenia, engrafted, 225, 260 

Headaches, 77 

Hearing of voices, 7 

Hereditary predisposition, 209, 332, 
258 

Hysteria, 270, 309 

Ideas, hypochondriacal, 103* 134, 

— of exaltation, 29, 95, 114, 125, 135, 

158, 171, 287, 302, 310 
influence, 16, 28, 124, X35, 287, 

317 
persecution, 27, 105, 112, 124, 

166, 284, 305, 310, 316 

reference, 31 

sin, 27, 105, 112, 124, 133 

— sexual, 16, 30, 157, 169, 288, 318 
Idiocy, 260 

Idiosyncrasy, personal, 235 

Imbecility, 260 

Immunization, 278 

Imprisonment, 118, 124, 133, 154, 177, 

241, 272, 327 
Impulsive actions, 40 
Incoherence of thought, 20, 56 
Infections, 240 
Influence on thought, 12, 170 

volition, 37, 170 

Inner negativism, 49, 51 
Inquisitiveness, 7 
" Intellectual negativism," 21, 49 
Internal speech, 67 
Intrapsychic co-ordination, 75 

Judgment, 25 
Jung, 246, 249 

Leucocytosis, 281 
Life traumata, 35, 51 



Mania, 308, 315 

Manic-depressive insanity, 131, 256, 

260, 309 
Mannerisms, 45, 107, 163, 284 
Memory, 17 
Menses, 85, 129 
Mental efliciency, 23 

— over-eierlion, 240 
Metabolism, 86, 243 

Mood, 106, 114, 119, 125, 136, 152, 
161, 172, 178, 190, 195, 196, 198, 
199, 201, 202, 205, 267, 293, 306, 

314, 325 
Morbid anatomy, 213 
relation to the clinical picture, 

219 
Mortality, 211 
Mutism, 65 

Negativism, 21, 47, 108, 115, 141, 
163, 265 

— in speech, 64 

Neologisms, 67, 140, 179, 284, 325 
Nomenclature, 3 
Nourishment, 87, 102, 144 

Obedience, automatic, 37, 107, 

142 
Objections, 3 
Occupation, 281 
CEdipus complex, 91 
Orientation, 17, ill 

Packs, wet, 279 

Parabulia, 47 

Paralogia, 21 

Paralysis, 275 

Paramimia, 75 

Paranoia, 276, 284, 300 

Paranoid forms, delimitation of, 252 

Paranoid weakmindedness, 195 

Paraphasia, 67 

Paraphrenia, 2, 253, 277, 282 

— confabulans, 309 

— expansiva, 302 

— phantastica, 315 

— systematica, 284, 308 
Parathyroidin, 278 
Pturathyroid glands, 278 
Parergasia, 47 

Perception, 5, 105, in, 123, 291 



INDEX 



331 



Personal idiosyncrasy, 235 
Personality, 53, 76 
Poems, 6g, 10 1 
Practical efficiency, 54 
Predisposition, 209, 232, 258 
Prc^nostic indications, 205 
Prophylaxis, 279 
Pseudo-memories, 18, 159, 292, 306, 

309. 322 
Psychic symptoms, 5 
Psychogenic psychoses, 272 
Psychomotor disorders, 79 
Psychopathic states, 209, 232, 258 
Psycho-reaction, 255 
Pupils, 77, 208, 272 

Recovery, 185, 256 
— with defect, 186, 205 
Reflexes, tendon, 79 
Remissions, 181 

Reproduction, 242 
Respiration, 84 
Retention, 18 

Saliva, 84 
Schizophrenia, I, 76 
Seizures, 81, 266, 272 
Self-expression, 55 
Sex, 210, 230 
Sexual life, 131, 242 
Simple weakmindedness, 189 
Sleep, 87, 102 
Spasmodic phenomena, 83 



Speaking past a subject, 72 
Speech, 56, 140, 164, 179, 203 
Speech, derailments of, 65, 179 
Stereotypy in speech, 62 

train of thought, 2 1 

writing, 63 

movement, 43, 107, 138, 206 

Stupor, negativistic, 50, 108, 141 
Susceptibility to influence, 37 
Syntax, 71 
Syphilis, 235, 241, 301 

— cerebral, 275 

Temperature, 84 
Tendon reflexes, 79 
Terminal states, 185 
Thoughts heard, 12 
Thyroid gland, 87, 243, 278 
Traumata of life, 35, 51 
Treatment, 278, 302, 328 

Vasomotor disorders, 84 
Verbigeration, 63, 140 

— hallucinatory, 11 
Voices, hearing of, 7 

Volition, 37, 74, 106, 115, 127, 138, 
198, 200 

Waxy flexibility, 38, 115 
Weakmindedness, hallucinatory, 192, 
206 

— paranoid, 195, 206 

— simple, 189, 205 
Writing, 57, 99, 174 



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